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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., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

This article describes the origins of the Division of Health Appraisal in Southern California Permanente Medical Group's San Diego Department of Preventive Medicine, which provided a comprehensive and nontraditional array of preventive medicine services to more than 50,000 members a year. The fusion of Health Appraisal with the Positive Choice risk abatement services provided the origins of the now internationally recognized Adverse Childhood Experiences Study and its major implications for the outcomes and costs of medical care.The Health Appraisal system fulfilled the medical evaluation and preventive needs of most adult patients outside of the traditional and costly sickness-care system, provided rapid access to medical care, has been medically reliable and appreciated by patients, and demonstrably reduced the cost of medical care while providing each evaluated member with a comprehensive medical record in a specialized database. The unexpected resistance to this concept's further implementation deserves exploration and understanding given the current problems in medical care.This article will discuss: Health Appraisal development and function; the Health Appraisal process; perspectives on the Health Appraisal product, outcomes, and benefits; and the Positive Choice system that linked Health Appraisal to prevention activities. A proposal for program expansion and the major economic implications of certain Adverse Childhood Experiences Study findings also will be discussed.

Case: A senior member of a 5-person pediatric group recently heard a presentation about the Adverse Childhood Experiences (ACE) study. He decided to present the study to his colleagues with the intention of incorporating a similar screening tool for ACE in their practice.The ACE study assessed adverse child experiences recalled by 17,000 adult patients who were participating in a comprehensive medical evaluation at a large Health Maintenance Organization. The ACE questionnaire assessed emotional, physical, and sexual abuse; emotional and physical neglect; mother treated violently; household substance abuse; household mental abuse; parental separation or divorce; and incarcerated household members (http://www.acestudy.org/yahoo&#95;site&#95;admin/assets/docs/ACE&#95;Calculator-English.127143712.pdf).Thirty-six percent of the participants did not endorse any ACE. One, 2 or 3 ACE's were endorsed by 26%, 16%, and 9.5%, respectively. Four or more ACEs were endorsed by 12% of the cohort. The study found that "the major risk factors for causes of death in adults, smoking, alcohol abuse, obesity, physical inactivity, use of illicit drugs, promiscuity, and suicide attempts, were all increased by ACEs. Compared with persons with an ACE score of 0, those with an ACE score of 4 or more were twice as likely to be smokers, 12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs" (2).When he researched the ACE study further, the pediatrician discovered that there was a modified form of the ACE study questions available for parents of children and adolescents. The members of the pediatric practice were intrigued by the reported relationship between ACEs and the high prevalence of chronic physical and mental health conditions and economic outcomes. Could this be a method for pediatricians to screen for risks of serious physical and psychiatric diseases in adult life? A brisk discussion followed about what they would do with this information if the ACE screening questions were used in their practice. Is it an effective strategy for primary care pediatric practice?

Medical research on "adverse childhood experiences" (ACEs) reveals a compelling relationship between the extent of childhood adversity, adult health risk behaviors, and principal causes of death in the United States. This article provides a selective review of the ACE Study and related social science research to describe how effective social work practice that prevents ACEs and mobilizes resilience and recovery from childhood adversity could support the achievement of national health policy goals. This article applies a biopsychosocial perspective, with an emphasis on mind-body coping processes to demonstrate that social work responses to adverse childhood experiences may contribute to improvement in overall health. Consistent with this framework, the article sets forth prevention and intervention response strategies with individuals, families, communities, and the larger society. Economic research on human capital development is reviewed that suggests significant cost savings may result from effective implementation of these strategies.

Background: Few reports have addressed associations between family strengths during childhood and adolescent pregnancy and its consequences. We examined relationships among a number of childhood family strengths and adolescent pregnancy, risk behavior, and psychosocial consequences after adolescent pregnancy., Methods: Our retrospective cohort of 4648 women older than 18 years (mean age, 56 years) received primary care in San Diego, CA. Outcomes included adolescent pregnancy and psychosocial consequences compared with number of the following childhood family strengths: family closeness, support, loyalty, protection, love, importance, and responsiveness to health needs., Results: Of the cohort, 3082 participants (66%) reported 6 or 7 categories of childhood family strengths. Teen pregnancy occurred in 39%, 33%, 30%, 25%, 24%, 21%, and 19% of those with 0 or 1, 2, 3, 4, 5, 6, and 7 childhood family strengths, respectively (p for trend < 0.00001). When childhood abuse and household dysfunction were present, adjusted odds ratios (ORs) for adolescent pregnancy demonstrated an increasingly protective effect as numbers of childhood family strengths increased from 0 or 1 to 2 or 3, 4 or 5, and 6 or 7 (1.0 to 0.80), (1.0 to 0.80, 0.60, and 0.54, respectively). These findings were partly explained by progressive delays in initiation of sexual activity as the number of childhood family strengths increased. Adjusted ORs for psychosocial problem occurring decades later decreased as the number of childhood family strengths increased from 0 or 1 to 2 or 3, 4 or 5, and 6 or 7 (job problems, 1.0, 0.8, 0.6, 0.4; family problems, 1.0, 1.1, 0.7, 0.6; financial problems, 1.0, 0.9, 0.9, 0.6; high stress, 1.0, 1.1, 0.9, 0.8; uncontrollable anger, 1.0, 0.7, 0.7, 0.4)., Conclusions: Childhood family strengths are strongly protective against adolescent pregnancy, early initiation of sexual activity, and long-term psychosocial consequences.

Background: Strong relationships between exposure to childhood traumatic stressors and smoking behaviours inspire the question whether these adverse childhood experiences (ACEs) are associated with an increased risk of lung cancer during adulthood., Methods: Baseline survey data on health behaviours, health status and exposure to adverse childhood experiences (ACEs) were collected from 17,337 adults during 1995-1997. ACEs included abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members with mentally ill, substance abusers, or sent to prison. We used the ACE score (an integer count of the 8 categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. Two methods of case ascertainment were used to identify incident lung cancer through 2005 follow-up: 1) hospital discharge records and 2) mortality records obtained from the National Death Index., Results: The ACE score showed a graded relationship to smoking behaviors. We identified 64 cases of lung cancer through hospital discharge records (age-standardized risk = 201 x 100,000(-1) population) and 111 cases of lung cancer through mortality records (age-standardized mortality rate = 31.1 x 100,000(-1) person-years). The ACE score also showed a graded relationship to the incidence of lung cancer for cases identified through hospital discharge (P = 0.0004), mortality (P = 0.025), and both methods combined (P = 0.001). Compared to persons without ACEs, the risk of lung cancer for those with >or= 6 ACEs was increased approximately 3-fold (hospital records: RR = 3.18, 95%CI = 0.71-14.15; mortality records: RR = 3.55, 95%CI = 1.25-10.09; hospital or mortality records: RR = 2.70, 95%CI = 0.94-7.72). After a priori consideration of a causal pathway (i.e., ACEs --> smoking --> lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with >or= 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs., Conclusions: Adverse childhood experiences may be associated with an increased risk of lung cancer, particularly premature death from lung cancer. The increase in risk may only be partly explained by smoking suggesting other possible mechanisms by which ACEs may contribute to the occurrence of lung cancer.

Background: Strong, graded relationships between exposure to childhood traumatic stressors and numerous negative health behaviors and outcomes, healthcare utilization, and overall health status inspired the question of whether these adverse childhood experiences (ACEs) are associated with premature death during adulthood., Purpose: This study aims to determine whether ACEs are associated with an increased risk of premature death during adulthood., Methods: Baseline survey data on health behaviors, health status, and exposure to ACEs were collected from 17,337 adults aged >18 years during 1995-1997. The ACEs included abuse (emotional, physical, sexual); witnessing domestic violence; parental separation or divorce; and growing up in a household where members were mentally ill, substance abusers, or sent to prison. The ACE score (an integer count of the eight categories of ACEs) was used as a measure of cumulative exposure to traumatic stress during childhood. Deaths were identified during follow-up assessments (between baseline appointment date and December 31, 2006) using mortality records obtained from a search of the National Death Index. Expected years of life lost (YLL) and years of potential life lost (YPLL) were computed using standard methods. The relative risk of death from all causes at age < or =65 years and at age < or =75 years was estimated across the number of categories of ACEs using multivariable-adjusted Cox proportional hazards regression. Analysis was conducted during January-February 2009., Results: Overall, 1539 people died during follow-up; the crude death rate was 91.0 per 1000; the age-adjusted rate was 54.7 per 1000. People with six or more ACEs died nearly 20 years earlier on average than those without ACEs (60.6 years, 95% CI=56.2, 65.1, vs 79.1 years, 95% CI=78.4, 79.9). Average YLL per death was nearly three times greater among people with six or more ACEs (25.2 years) than those without ACEs (9.2 years). Roughly one third (n=526) of those who died during follow-up were aged < or =75 years at the time of death, accounting for 4792 YPLL. After multivariable adjustment, adults with six or more ACEs were 1.7 (95% CI=1.06, 2.83) times more likely to die when aged < or =75 years and 2.4 (95% CI=1.30, 4.39) times more likely to die when aged < or =65 years., Conclusions: ACEs are associated with an increased risk of premature death, although a graded increase in the risk of premature death was not observed across the number of categories of ACEs. The increase in risk was only partly explained by documented ACE-related health and social problems, suggesting other possible mechanisms by which ACEs may contribute to premature death.

Background: To assess the association between adverse childhood experiences (ACEs), including childhood abuse and neglect, and serious household dysfunction, and premature death of a family member. Because ACEs increase the risk for many of the leading causes of death in adults and tend to be familial and intergenerational, we hypothesized that persons who report having more ACEs would be more likely to have family members at risk of premature death., Methods: We used data from 17,337 adult health plan members who completed a survey about 10 types of ACEs and whether a family member died before age 65. The prevalence of family member premature death and its association with ACEs were assessed., Results: Family members of respondents who experienced any type of ACEs were more likely to have elevated prevalence for premature death relative to those of respondents without such experience (p < 0.01). The highest risk occurred among those who reported having been physically neglected and living with substance abusing or criminal family members during childhood. A powerful graded relationship between the number of ACEs and premature mortality in the family was observed for all age groups, and comparison between groups reporting 0 ACE and >or= 4 ACEs yielded an OR of 1.8 (95%CI, 1.6-2.0)., Conclusion: Adverse childhood experiences may be an indicator of a chaotic family environment that results in an increased risk of premature death among family members.

Objective: To examine whether childhood traumatic stress increased the risk of developing autoimmune diseases as an adult., Methods: Retrospective cohort study of 15,357 adult health maintenance organization members enrolled in the Adverse Childhood Experiences (ACEs) Study from 1995 to 1997 in San Diego, California, and eligible for follow-up through 2005. ACEs included childhood physical, emotional, or sexual abuse; witnessing domestic violence; growing up with household substance abuse, mental illness, parental divorce, and/or an incarcerated household member. The total number of ACEs (ACE Score range = 0-8) was used as a measure of cumulative childhood stress. The outcome was hospitalizations for any of 21 selected autoimmune diseases and 4 immunopathology groupings: T- helper 1 (Th1) (e.g., idiopathic myocarditis); T-helper 2 (Th2) (e.g., myasthenia gravis); Th2 rheumatic (e.g., rheumatoid arthritis); and mixed Th1/Th2 (e.g., autoimmune hemolytic anemia)., Results: Sixty-four percent reported at least one ACE. The event rate (per 10,000 person-years) for a first hospitalization with any autoimmune disease was 31.4 in women and 34.4 in men. First hospitalizations for any autoimmune disease increased with increasing number of ACEs (p < .05). Compared with persons with no ACEs, persons with >or=2 ACEs were at a 70% increased risk for hospitalizations with Th1, 80% increased risk for Th2, and 100% increased risk for rheumatic diseases (p < .05)., Conclusions: Childhood traumatic stress increased the likelihood of hospitalization with a diagnosed autoimmune disease decades into adulthood. These findings are consistent with recent biological studies on the impact of early life stress on subsequent inflammatory responses.

Background: Prescription drugs account for approximately 11% of national health expenditures. Prior research on adverse childhood experiences (ACEs), which include common forms of child maltreatment and related traumatic stressors, has linked them to numerous health problems. However, data about the relationship of these experiences to prescription drug use are scarce., Method: We used the ACE Score (an integer count of 8 different categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. We prospectively assessed the relationship of the Score to prescription drug use in a cohort of 15,033 adult HMO patients (mean follow-up: 6.1 years) and assessed mediation of this relationship by documented ACE-related health and social problems., Results: Nearly 1.2 million prescriptions were recorded; prescriptions rates increased in a graded fashion as the ACE Score increased (p for trend < 0.0001). Compared to persons with an ACE Score of 0, persons with a Score > or = 5 had rates increased by 40%; graded relationships were seen for all age groups (18-44, 45-64, and 65-89 years) (p for trend < 0.01). Graded relationships were observed for the risk of being in the upper decile of number of classes of drugs used; persons with scores of > or = 5 had this risk increased 2-fold. Adjustment for ACE-related health problems reduced the strength of the associations by more than 60%., Conclusion: ACEs substantially increase the number of prescriptions and classes of drugs used for as long as 7 or 8 decades after their occurrence. The increases in prescription drug use were largely mediated by documented ACE-related health and social problems.

Background: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the U.S. However, little is known about the influence of childhood stressors on its occurrence., Methods: Data were from 15,472 adult HMO members enrolled in the Adverse Childhood Experiences (ACE) Study from 1995 to 1997 and eligible for the prospective phase. Eight ACEs were assessed: abuse (emotional, physical, sexual); witnessing domestic violence; growing up with substance-abusing, mentally ill, or criminal household members; and parental separation or divorce. The number of ACEs (ACE Score) was used to examine the relationship of childhood stressors to the risk of COPD. Three methods of case ascertainment were used to define COPD: baseline reports of prevalent COPD, incident hospitalizations with COPD as a discharge diagnosis, and rates of prescription medications to treat COPD during follow-up. Follow-up data were available through 2004., Results: The ACE Score had a graded relationship to each of three measures of the occurrence of COPD. Compared to people with an ACE Score of 0, those with an ACE Score of > or =5 had 2.6 times the risk of prevalent COPD, 2.0 times the risk of incident hospitalizations, and 1.6 times the rates of prescriptions (p<0.01 for all comparisons). These associations were only modestly reduced by adjustment for smoking. The mean age at hospitalization decreased as the ACE Score increased (p<0.01)., Conclusions: Decades after they occur, adverse childhood experiences increase the risk of COPD. Because this increased risk is only partially mediated by cigarette smoking, other mechanisms by which ACEs may contribute to the occurrence of COPD merit consideration.

Because the penetrance of HFE hemochromatosis is low, traditional population screening measuring the transferrin saturation is unlikely to be cost-effective because the majority of subjects detected neither have clinical disease nor are likely to develop it. Three independent studies show that only patients with serum ferritin concentrations more than 1000 microg/L are at risk for cirrhosis, one of the main morbidities of hemochromatosis. Among 29,699 white subjects participating in the Scripps/Kaiser hemochromatosis study, only 59 had serum ferritin levels more than 1000 microg/L; 24 had homozygous mutant or compound heterozygous mutant HFE genotypes. In all but 5 of the other subjects, the causes of elevated ferritin were excessive alcohol intake, cancer, or liver disease. Screening for hemochromatosis with serum ferritin levels will detect the majority of patients who will be clinically affected and may detect other clinically significant disease in patients who do not have hemochromatosis genotypes. Because the ferritin level of the majority of adult homozygotes for HFE mutations does not rise over long periods of time, excluding subjects with serum ferritin levels less than or equal to 1000 microg/L should not result in missed opportunities for early treatment of patients who could benefit.

Objective: To examine relationships between childhood autobiographical memory disturbance (CAMD) and adverse childhood experiences (ACEs) which are defined as common forms of child maltreatment and related traumatic stressors., Methods: We use the ACE score (an integer count of eight different categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. In a cross sectional analysis we assess the relationship of the ACE score to the prevalence of CAMD in a sample of 9,460 relatively healthy adults evaluated for wellness care at a southern California health maintenance organization between August 1995 and March 1996. In addition, we examined possible secular influences by examining association among each of four birth cohorts. Logistic regression was used to obtain the adjusted relative odds of CAMD associated with increasing ACE score., Results: Overall, the age-standardized prevalence of CAMD was 18% (men: 15%; women: 19%). As the ACE score increased, the prevalence of CAMD increased in a graded fashion for both men and women (p for trend <.0001). After adjustment for age, sex, race/ethnicity, and education, adults with an ACE score >or=6 were 5.9 (95% CI, 4.4-7.9) times more likely to have CAMD compared to adults with an ACE score of 0. The prevalence of CAMD increased with each successive birth cohort, and graded relationships between the ACE score and CAMD were observed among each of the four birth cohorts though no statistical difference in the association was found across birth cohorts., Conclusions: The accumulation of ACEs across several domains is associated CAMD among men and women and in each of four birth cohorts. Further research is needed that describes the prevalence of CAMD in population-based samples and that examines whether impaired memory is a marker for persons neurobiologically affected by multiple forms of child maltreatment and related traumatic stressors.

Objective: To examine agreement between self-reported exposure to lipid-lowering medications and objective evidence of filling prescribed lipid-lowering medications., Study Design and Setting: Using data from 7,918 adults from the Adverse Childhood Experiences (ACE) Study, we calculated the sensitivity, specificity, and positive (PV+) and negative (PV-) predictive values, and likelihood ratios for self-reported exposure to lipid-lowering medications compared to exposure obtained from pharmacy claims (gold standard) both overall and by age, sex, race/ethnicity, education, and ACE Score., Results: Eight percent (n=655) of adults self-reported lipid-lowering medication exposure, and 379 adults filled at least one lipid-lowering prescription within 60 days of the baseline exam during 1997. The sensitivity of self-reported exposure was nearly 94%; the specificity was 96%; the PV+ was 54%; and the PV- was nearly 100%. Values for sensitivity, specificity, PV+, and PV- were similar across participant characteristics., Conclusion: A self-reported measure of lipid-lowering medication exposure was accurate with high sensitivity and specificity while the PV+ of self-reported lipid-lowering medication exposure was relatively low. These findings suggest that self-reported exposure to lipid-lowering medications may be useful in surveys that examine the prevalence of hyperlipidemia, but may overestimate actual exposure in studies monitoring trends in use of lipid-lowering medications.

Background: Prescription drugs are one of the fastest growing healthcare costs in the United States. However, the long-term influence of child abuse and related traumatic stressors on prescriptions for psychotropic medications in adults has not been described. This study assessed the relationship of eight adverse childhood experiences (ACEs) to rates of prescriptions for psychotropic medications throughout adulthood. These ACEs included: abuse (emotional, physical, or sexual), witnessing domestic violence, growing up with substance abusing, mentally ill, or criminal household members, and parental separation/divorce., Methods: Data about ACEs were collected between 1995 and 1997 from adult health maintenance organization patients; prescription data were available from 1997 to 2004. The number of ACEs (ACE Score: maximum 8) was used as a measure of cumulative traumatic stress during childhood. The relationship of the score to rates of prescribed psychotropic drugs was prospectively assessed among 15,033 adult patients eligible for the follow-up phase of the study (mean follow-up: 6.1 years). Data were analyzed in 2006. Multivariate models were adjusted for age, race, gender, and education., Results: Prescription rates increased yearly during the follow-up and in a graded fashion as the ACE Score increased (p for trend <0.001). After adjusting compared with persons with an ACE Score of 0, persons with a score of equal to or more than 5 had a nearly threefold increase in rates of psychotropic prescriptions. Graded relationships were observed between the score and prescription rates for antidepressant, anxiolytic, antipsychotic, and mood-stabilizing/bipolar medications; rates for persons with a score of equal to or more than 5 for these classes of drugs increased 3-, 2-, 10-, and 17-fold, respectively., Conclusions: The strong relationship of the ACE Score to increased utilization of psychotropic medications underscores the contribution of childhood experience to the burden of adult mental illness. Moreover, the huge economic costs associated with the use of psychotropic medications provide additional incentive to address the high prevalence and consequences of childhood traumatic stressors.

Objectives: Little is known about why people continue to smoke after learning that they have diseases and conditions that contraindicate smoking. Using data from the Adverse Childhood Experiences (ACE) Study, we examined the relation between ACEs and smoking behavior when smoking-related illnesses or conditions are present, both with and without depression as a mediator., Methods: Participants were more than 17,000 adult HMO members who retrospectively reported on eight categories of ACEs (emotional, physical, and sexual abuse; witnessing interparental violence; parental divorce; and growing up with a substance-abusing, mentally ill, or incarcerated household member). The number of maltreatment categories was summed to form an ordinal variable called the ACE Score. We measured current smoking, conditions that contraindicate smoking (heart disease, chronic lung disease, and diabetes), and symptoms of these illnesses (chronic bronchitis, chronic cough, and shortness of breath). Logistic regression models compared the ACE Score of smokers with smoking-related illnesses to participants who reported these illnesses but were not current smokers (n = 7483)., Results: Significant dose-response relations between the ACE Score and smoking persistence were found (odds ratio = 1.69; confidence interval = 1.34-2.13 for participants with ≥4 ACEs). Depression was a significant independent predictor of smoking persistence as well as a mediator. Depression only slightly attenuated the relation between the ACE Score and persistent smoking, however., Conclusion: Medical practitioners should consider the maltreatment history and depression status of their patients when a smoking-related diagnosis fails to elicit smoking cessation. Programs should be developed that better address the underlying motivations for continuing to smoke in the face of health problems that contraindicate smoking.

Background: Childhood maltreatment has been linked to a variety of changes in brain structure and function and stress-responsive neurobiological systems. Epidemiological studies have documented the impact of childhood maltreatment on health and emotional well-being., Methods: After a brief review of the neurobiology of childhood trauma, we use the Adverse Childhood Experiences (ACE) Study as an epidemiological "case example" of the convergence between epidemiologic and neurobiological evidence of the effects of childhood trauma. The ACE Study included 17,337 adult HMO members and assessed 8 adverse childhood experiences (ACEs) including abuse, witnessing domestic violence, and serious household dysfunction. We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a "dose-response" relationship of the ACE score to 18 selected outcomes and to the total number of these outcomes (comorbidity)., Results: Based upon logistic regression analysis, the risk of every outcome in the affective, somatic, substance abuse, memory, sexual,and aggression-related domains increased in a graded fashion as the ACE score increased (P <0.001). The mean number of comorbid outcomes tripled across the range of the ACE score., Conclusions: The graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions.

Purpose: Alcohol is the most common and frequently used drug and has the potential to cause multiple deleterious effects throughout the lifespan. Because early age at initiation of alcohol use increases this potential and programs and laws are in place to attempt to delay the onset of alcohol use, we studied the relationship between multiple adverse childhood experiences (ACEs) and both the likelihood of ever drinking and the age at initiating alcohol use., Methods: This was a retrospective cohort study of 8417 adult health maintenance organization (HMO) members in California who completed a survey about ACEs, which included childhood abuse and neglect, growing up with various forms of household dysfunction and alcohol use in adolescence and adulthood. The main outcomes measured were ever drinking and age at initiating alcohol use among ever-drinkers for four age categories: < or = 14 years (early adolescence), 15 to 17 years (mid adolescence), and 18 to 20 years (late adolescence); age > or = 21 years was the referent. The relationship between the total number of adverse childhood experiences (ACE score) and early initiation of alcohol use (< or =14 years) among four birth cohorts dating back to 1900 was also examined., Results: Eighty-nine percent of the cohort reported ever drinking; all individual ACEs except physical neglect increased the risk of ever using alcohol (p < .05). Among ever drinkers, initiating alcohol use by age 14 years was increased two- to threefold by individual ACEs (p < .05). ACEs also accounted for a 20% to 70% increased likelihood of alcohol use initiated during mid adolescence (15-17 years). The total number of ACEs (ACE score) had a very strong graded relationship to initiating alcohol use during early adolescence and a robust but somewhat less strong relationship to initiation during mid adolescence. For each of the four birth cohorts, the ACE score had a strong, graded relationship to initiating alcohol use by age 14 years (p < .05)., Conclusions: Adverse childhood experiences are strongly related to ever drinking alcohol and to alcohol initiation in early and mid adolescence, and the ACE score had a graded or "dose-response" relationship to these alcohol use behaviors. The persistent graded relationship between the ACE score and initiation of alcohol use by age 14 for four successive birth cohorts dating back to 1900 suggests that the stressful effects of ACEs transcend secular changes, including the increased availability of alcohol, alcohol advertising, and the recent campaigns and health education programs to prevent alcohol use. These findings strongly suggest that efforts to delay the age of onset of drinking must recognize the contribution of multiple traumatic and stressful events to alcohol-seeking behavior among children and adolescents.

Background: Throughout US history, US society has been characterized by its high degree of residential mobility. Previous data suggest a relationship between mobility and increased health risk, but this relationship might be confounded by unmeasured adverse childhood experiences (ACEs)., Objectives: To examine the relationship of childhood residential mobility to health problems during adolescence and adulthood and to determine how much these apparent relationships may result from underlying ACEs., Design, Setting, and Participants: Retrospective cohort study of 8116 adults who completed a survey that included childhood residential mobility, ACEs (childhood abuse, childhood neglect, and household dysfunction), and multiple health problems., Main Outcome Measures: Number of childhood residential moves and number of ACEs (ACE score) were assessed for relationships to depressed affect, attempted suicide, alcoholism, smoking, early sexual initiation, and teenaged pregnancy., Results: After adjustment for demographic variables, the risk of high residential mobility during childhood (> or = 8 moves) was 1.7- to 3.1-fold for each ACE, and increased with the number of ACEs. Compared with respondents who never moved, the odds of health risk for respondents with high mobility during childhood ranged from 1.3 (for smoking) to 2.5 (for suicide). However, when the number of ACEs was entered into multivariate models, the relationship between mobility and health problems was greatly reduced., Conclusions: Adverse childhood experiences are strongly associated with frequent residential mobility. Moreover, the apparent relationship between childhood mobility and various health risks is largely explained by ACEs. Thus, previous studies showing a relationship between residential mobility and negative outcomes were likely confounded by unmeasured ACEs.

Objective: Little information is available about the contribution of multiple adverse childhood experiences (ACEs) to the likelihood of reporting hallucinations. We used data from the ACE study to assess this relationship., Methods: We conducted a survey about childhood abuse and household dysfunction while growing up, with questions about health behaviors and outcomes in adulthood, which was completed by 17,337 adult HMO members in order to assess the independent relationship of 8 adverse childhood experiences and the total number of ACEs (ACE score) to experiencing hallucinations. We used logistic regression to assess the relationship of the ACE score to self-reported hallucinations., Results: We found a statistically significant and graded relationship between histories of childhood trauma and histories of hallucinations that was independent of a history of substance abuse. Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations., Conclusion: These findings suggest that a history of childhood trauma should be looked for among persons with a history of hallucinations.

Background: Childhood sexual abuse (CSA) is a worldwide problem. Although most studies on the long-term consequences of CSA have focused on women, sexual abuse of both boys and girls is common. Thus, a comparison of the long-term effects of CSA by gender of the victim will provide perspective on the need for future research, prevention activities, and treatment of survivors., Methods: A retrospective cohort study was conducted from 1995 to 1997 among 17,337 adult HMO members in San Diego, California. Participants completed a survey about abuse or household dysfunction during childhood, and multiple other health-related issues. Multivariate logistic regression was used to examine the relationships between severity of CSA (intercourse vs no intercourse) and long-term health and social problems (substance use and abuse, mental illness, and current problems with marriage and family) by gender of victim. Models controlled for exposure to other forms of adverse childhood experiences that co-occur with CSA. Among men, the relationship between the gender of the CSA perpetrator to the outcomes was also examined., Results: Contact CSA was reported by 16% of males and 25% of females. Men reported female perpetration of CSA nearly 40% of the time, and women reported female perpetration of CSA 6% of the time. CSA significantly increased the risk of the outcomes. The magnitude of the increase was similar for men and women. For example, compared to reporting no sexual abuse, a history of suicide attempt was more than twice as likely among both men and women who experienced CSA (p<0.05). Compared with those who did not report CSA, men and women exposed to CSA were at a 40% increased risk of marrying an alcoholic, and a 40% to 50% increased risk of reporting current problems with their marriage (p<0.05)., Conclusions: In this cohort of adult HMO members, experiencing CSA was common among both men and women. The long-term impact of CSA on multiple health and social problems was similar for both men and women. These findings strongly indicate that boys and girls are vulnerable to this form of childhood maltreatment; the similarity in the likelihood for multiple behavioral, mental, and social outcomes among men and women suggests the need to identify and treat all adults affected by CSA.

Objective: We examined the relation between eight types of adverse childhood experience (ACE) and three indicators of impaired worker performance (serious job problems, financial problems, and absenteeism)., Methods: We analyzed data collected for the Adverse Childhood Experiences Study from 9633 currently employed adult members of the Kaiser Foundation Health Plan in San Diego., Results: Strong graded relations were found between the ACE Score (total number of ACE categories experienced) and each measure of impaired worker performance (p < .001). We found strong evidence that the relation between ACE Score and worker performance was mediated by interpersonal relationship problems, emotional distress, somatic symptoms, and substance abuse., Conclusions: The long-term effects of adverse childhood experiences on the workforce impose major human and economic costs that are preventable. These costs merit attention from the business community in conjunction with specialists in occupational medicine and public health.

Background: Research examining the association between childhood abuse and depressive disorders has frequently assessed abuse categorically, thus not permitting discernment of the cumulative impact of multiple types of abuse. As previous research has documented that adverse childhood experiences (ACEs) are highly interrelated, we examined the association between the number of such experiences (ACE score) and the risk of depressive disorders., Methods: Retrospective cohort study of 9460 adult health maintenance organization members in a primary care clinic in San Diego, CA who completed a survey addressing a variety of health-related concerns, which included standardized assessments of lifetime and recent depressive disorders, childhood abuse and household dysfunction., Results: Lifetime prevalence of depressive disorders was 23%. Childhood emotional abuse increased risk for lifetime depressive disorders, with adjusted odds ratios (ORs) of 2.7 [95% confidence interval (CI), 2.3-3.2] in women and 2.5 (95% CI, 1.9-3.2) in men. We found a strong, dose-response relationship between the ACE score and the probability of lifetime and recent depressive disorders (P<0.0001). This relationship was attenuated slightly when a history of growing up with a mentally ill household member was included in the model, but remained significant (P<0.001)., Conclusions: The number of ACEs has a graded relationship to both lifetime and recent depressive disorders. These results suggest that exposure to ACEs is associated with increased risk of depressive disorders up to decades after their occurrence. Early recognition of childhood abuse and appropriate intervention may thus play an important role in the prevention of depressive disorders throughout the life span.

Background: The purpose of this study was to assess the relation of adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, to the risk of ischemic heart disease (IHD) and to examine the mediating impact on this relation of both traditional IHD risk factors and psychological factors that are associated with ACEs., Methods and Results: Retrospective cohort survey data were collected from 17,337 adult health plan members from 1995 to 1997. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACE-IHD relation and the mediating impact of IHD risk factors in this relation. Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with > or =7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE-IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. We observed significant association between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7., Conclusions: We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

Objective: Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence., Method: We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors., Results: Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p <.0001), confirming the statistical interrelatedness of ACEs., Conclusions: The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes.

Objectives: Few reports address the impact of cumulative exposure to childhood abuse and family dysfunction on teen pregnancy and consequences commonly attributed to teen pregnancy. Therefore, we examined whether adolescent pregnancy increased as types of adverse childhood experiences (ACE score) increased and whether ACEs or adolescent pregnancy was the principal source of elevated risk for long-term psychosocial consequences and fetal death., Design, Setting, and Participants: A retrospective cohort study of 9159 women aged > or = 18 years (mean 56 years) who attended a primary care clinic in San Diego, California in 1995-1997., Main Outcome Measure: Adolescent pregnancy, psychosocial consequences, and fetal death, compared by ACE score (emotional, physical, or sexual abuse; exposure to domestic violence, substance abusing, mentally ill, or criminal household member; or separated/divorced parent)., Results: Sixty-six percent (n = 6015) of women reported > or = 1 ACE. Teen pregnancy occurred in 16%, 21%, 26%, 29%, 32%, 40%, 43%, and 53% of those with 0, 1, 2, 3, 4, 5, 6, and 7 to 8 ACEs. As the ACE score rose from zero to 1 to 2, 3 to 4, and > or = 5, odds ratios for each adult consequence increased (family problems: 1.0, 1.5, 2.2, 3.3; financial problems: 1.0, 1.6, 2.3, 2.4; job problems: 1.0, 1.4, 2.3, 2.9; high stress: 1.0, 1.4, 1.9, 2.2; and uncontrollable anger: 1.0, 1.6, 2.8, 4.5, respectively). Adolescent pregnancy was not associated with any of these adult outcomes in the absence of childhood adversity (ACEs: 0). The ACE score was associated with increased fetal death after first pregnancy (odds ratios for 0, 1-2, 3-4, and 5-8 ACEs: 1.0, 1.2, 1.4, and 1.8, respectively); teen pregnancy was not related to fetal death., Conclusions: The relationship between ACEs and adolescent pregnancy is strong and graded. Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying ACEs rather than adolescent pregnancy per se.

We find that in the Black American population average ferritin levels are higher than those in Whites, both among men and women. African-Americans have an increased prevalence of iron storage disease characterized by prominent iron deposition in macrophages of the liver and other organs. The iron distribution in patients with mutations of the ferroportin gene is similar. A c.744 G-->T (Gln 248 His) mutation was detected among African-Americans at polymorphic frequencies. This variant is associated with increased ferritin levels in African-Americans and may play a role in their propensity to develop iron overload.

A population-based analysis of over 17,000 middle-class American adults undergoing comprehensive, biopsychosocial medical evaluation indicates that three common categories of addiction are strongly related in a proportionate manner to several specific categories of adverse experiences during childhood. This, coupled with related information, suggests that the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent. This challenge to the usual concept of the cause of addictions has significant implications for medical practice and for treatment programs.

Background: Little is known about the relative advantages of video versus internet-based decision aids to facilitate shared medical decision making. This study compared internet and video patient education modalities for men considering the prostate specific antigen (PSA) test., Methods: Two hundred and twenty-six men, aged 50 years or older, and scheduled to complete a physical examination at an HMO Health Appraisal Clinic were randomly assigned to access a website (N = 114) or view a 23-minute videotape in the clinic (N = 112) prior to deciding whether they wanted to be screened for prostate cancer., Results: There were no between-groups differences in participants' ratings of convenience, effort, or satisfaction following exposure to the decision aid. Participants assigned to the video group were more likely to review the materials than individuals assigned to the internet group (98.2% vs 53.5%). Participants in the video group showed significantly greater increases in PSA knowledge and were more likely to decline the PSA test than individuals assigned to the internet group. However, participants in the internet group who reviewed the entire online presentation showed similar increases in PSA knowledge as video participants. Only 5% of all participants visited other websites to inform themselves about the PSA test., Conclusions: Overall, the video was significantly more effective than the Internet in educating participants about benefits and risks of PSA screening.

Objective: To examine the relationship of adverse childhood experiences (ACEs), including abuse, neglect, and forms of household dysfunction, to the risk of liver disease by assessing the role of risk behaviors, such as substance abuse and high-risk sexual activity, as mediators of the ACEs-liver disease relationship., Methods: Retrospective cohort study data were collected from 17 337 adult health plan members through a survey. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACEs-liver disease relationship and the impact of the mediators in this relationship., Results: Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs-liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship., Conclusions: The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACEs on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.

Background: We examined the relationship of the number of adverse childhood experiences (ACE score) to six health problems among four successive birth cohorts dating back to 1900 to assess the strength and consistency of these relationships in face of secular influences the 20th century brought in changing health behaviors and conditions. We hypothesized that the ACE score/health problem relationship would be relatively "immune" to secular influences, in support of recent studies documenting the negative neurobiologic effects of childhood stressors on the developing brain., Methods: A retrospective cohort study of 17,337 adult health maintenance organization (HMO) members who completed a survey about childhood abuse and household dysfunction, as well as their health. We used logistic regression to examine the relationships between ACE score and six health problems (depressed affect, suicide attempts, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts: 1900-1931, 1932-1946, 1947-1961, and 1962-1978., Results: The ACE score increased the risk for each health problem in a consistent, strong, and graded manner across four birth cohorts (P < 0.05). For each unit increase in the ACE score (range: 0-8), the adjusted odds ratios (ORs) for depressed affect, STDs, and multiple sexual partners were increased within a narrow range (ORs: 1.2-1.3 per unit increase) for each of the birth cohorts; the increase in risk for suicide attempts was stronger but also in a narrow range (ORs: 1.5-1.7)., Conclusions: Growing up with ACEs increased the risk of numerous health behaviors and outcomes for 20th century birth cohorts, suggesting that the effects of ACEs on the risk of various health problems are unaffected by social or secular changes. Research showing detrimental and lasting neurobiologic effects of child abuse on the developing brain provides a plausible explanation for the consistency and dose-response relationships found for each health problem across birth cohorts, despite changing secular influences.

Objective: This study examined the prevalence of a history of various combinations of childhood maltreatment types (physical abuse, sexual abuse, and witnessing of maternal battering) among adult members of a health maintenance organization (HMO) and explored the relationship with adult mental health of the combinations of types of childhood maltreatment and emotional abuse in the childhood family environment., Method: A total of 8,667 adult members of an HMO completed measures of childhood exposure to family dysfunction, which included items on physical and sexual abuse, witnessing of maternal battering, and emotional abuse in the childhood family environment. The adults' current mental health was assessed by using the mental health scale of the Medical Outcomes Study 36-item Short-Form Health Survey., Results: The prevalences of sexual abuse, physical abuse, and witnessing of maternal violence were 21.6%, 20.6%, and 14.0%, respectively, when the maltreatment types were considered separately. Among respondents reporting any of the maltreatment types, 34.6% reported more than one type of maltreatment. Lower mean mental health scores were associated with higher numbers of abuse categories (mean=78.5, 75.5, 72.8, and 69.9 for respondents with no, one, two, and three abuse types, respectively). Both an emotionally abusive family environment and the interaction of an emotionally abusive family environment with the various maltreatment types had a significant effect on mental health scores., Conclusions: Childhood physical and sexual abuse, as well as witnessing of maternal battering, were common among the adult members of an HMO in this study. Among those reporting any maltreatment, more than one-third had experienced more than one type of maltreatment. A dose-response relation was found between the number of types of maltreatment reported and mental health scores. In addition, an emotionally abusive family environment accentuated the decrements in mental health scores. Future research examining the effects of childhood maltreatment on adult mental health should include assessments of a wide range of abusive experiences, as well as the family atmosphere in which they occur.

Objective: This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction., Methods: Retrospective cohort study data were collected from 17,337 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score)., Results: CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < 0.05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < 0.01)., Conclusions: CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs.

Objective: Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed., Methods: We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use., Results: Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use., Conclusions: The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.