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Relationship of Childhood Abuse and Household Dysfunction ...

Research ArticleRelationship of Childhood Abuse andHousehold Dysfunction to Many of theLeading Causes of Death in AdultsThe Adverse Childhood Experiences (ACE) StudyVincent 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, MPHB ackground:The Relationship of health risk behavior and disease in adulthood to the breadth ofexposure to Childhood emotional, physical, or sexual Abuse , and Household dysfunctionduring Childhood has not previously been :A questionnaire about adverse Childhood experiences was mailed to 13,494 adults who hadcompleted a standardized medical evaluation at a large HMO; 9,508 ( ) categories of adverse Childhood experiences were studied: psychological, physical, orsexual Abuse ; violence against mother; or living with Household members who weresubstance abusers, mentally ill or suicidal, or ever imprisoned.

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

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Transcription of Relationship of Childhood Abuse and Household Dysfunction ...

1 Research ArticleRelationship of Childhood Abuse andHousehold Dysfunction to Many of theLeading Causes of Death in AdultsThe Adverse Childhood Experiences (ACE) StudyVincent 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, MPHB ackground:The Relationship of health risk behavior and disease in adulthood to the breadth ofexposure to Childhood emotional, physical, or sexual Abuse , and Household dysfunctionduring Childhood has not previously been :A questionnaire about adverse Childhood experiences was mailed to 13,494 adults who hadcompleted a standardized medical evaluation at a large HMO; 9,508 ( ) categories of adverse Childhood experiences were studied: psychological, physical, orsexual Abuse ; violence against mother; or living with Household members who weresubstance abusers, mentally ill or suicidal, or ever imprisoned.

2 The number of categoriesof these adverse Childhood experiences was then compared to measures of adult riskbehavior, health status, and disease. Logistic regression was used to adjust for effects ofdemographic factors on the association between the cumulative number of categories ofchildhood exposures (range: 0 7) and risk factors for the leading causes of death in :More than half of respondents reported at least one, and one-fourth reported$2categories of Childhood exposures. We found a graded Relationship between the numberof categories of Childhood exposure and each of the adult health risk behaviors anddiseases that were studied (P,.001).Persons who had experienced four or morecategories of Childhood exposure, compared to those who had experienced none, had 4-to 12-fold increased health risks for alcoholism, drug Abuse , depression, and suicideattempt; a 2- to 4-fold increase in smoking, poor self-rated health,$50 sexual intercoursepartners, and sexually transmitted disease; and a to increase in physicalinactivity and severe obesity.

3 The number of categories of adverse Childhood exposuresshowed a graded Relationship to the presence of adult diseases including ischemic heartdisease, cancer, chronic lung disease, skeletal fractures, and liver disease. The sevencategories of adverse Childhood experiences were strongly interrelated and persons withmultiple categories of Childhood exposure were likely to have multiple health risk factorslater in :We found a strong graded Relationship between the breadth of exposure to Abuse orhousehold Dysfunction during Childhood and multiple risk factors for several of theleading causes of death in Subject Headings (MeSH):child Abuse , sexual, domestic violence, spouse Abuse ,children of impaired parents, substance Abuse , alcoholism, smoking, obesity, physicalactivity, depression, suicide, sexual behavior, sexually transmitted diseases, chronic obstruc-tive pulmonary disease, ischemic heart disease.

4 (Am J Prev Med 1998;14:245 258) 1998 American Journal of Preventive MedicineDepartment of Preventive Medicine, Southern California Perma-nente Medical Group (Kaiser Permanente), (Felitti) San Diego,California 92111. National Center for Chronic Disease Preventionand Health Promotion, Centers for Disease Control and Prevention,(Anda, Williamson, Spitz, Edwards, Marks) Atlanta, Georgia 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 correspondence to: Vincent J. Felitti, MD, Kaiser Perma-nente, Department of Preventive Medicine, 7060 Clairemont MesaBoulevard, San Diego, California J Prev Med 1998;14(4)0749-3797/98/$ 1998 American Journal of Preventive MedicinePII S0749-3797(98)00017-8 IntroductionOnly recently have medical investigators in pri-mary care settings begun to examine associa-tions between Childhood Abuse and adulthealth risk behaviors and 5 These associationsare important because it is now clear that the leadingcauses of morbidity and mortality in the United States6are related to health behaviors and lifestyle factors.

5 These factors have been called the actual causes as Abuse and other potentiallydamaging Childhood experiences contributeto the development of these risk factors, thenthese Childhood exposures should be recog-nized as the basic causes of morbidity andmortality in adult sociologists and psychologistshave published numerous articles about thefrequency8 12and long-term consequenc-es13 15of Childhood Abuse , understanding their rele-vance to adult medical problems is rudimentary. Fur-thermore, medical research in this field has limitedrelevance to most primary care physicians because it isfocused on adolescent health,16 20mental health inadults,20or on symptoms among patients in ,23 Studies of the long-term effects of child-hood Abuse haveusually examined single types of Abuse ,particularly sexual Abuse , and few have assessed the im-pact of more than one type of ,24 28 Conditionssuch as drug Abuse , spousal violence, and criminal activityin the Household may co-occur with specific forms ofabuse that involvechildren.

6 Without measuring thesehousehold factors as well, long-term influence might bewrongly attributed solely to single types of Abuse andthe cumulative influence of multiple categories ofadverse Childhood experiences would not be our knowledge, the Relationship of adult health riskbehaviors, health status, and disease states to childhoodabuse and Household dysfunction29 35has not undertook the Adverse Childhood Experiences(ACE) Study in a primary care setting to describe thelong-term Relationship of Childhood experiences toimportant medical and public health problems. TheACE Study is assessing, retrospectively and prospec-tively, the long-term impact of Abuse and householddysfunction during Childhood on the following out-comes in adults: disease risk factors and incidence,quality of life, health care utilization, and mortality.

7 Inthis initial paper we use baseline data from the study toprovide an overview of the prevalence and interrelationof exposures to Childhood Abuse and Household dys-function. We then describe the Relationship betweenthe number of categories of these deleterious child-hood exposures and risk factors and those diseases thatunderlie many of the leading causes of death ,7,36,37 MethodsStudy SettingThe ACE Study is based at Kaiser Permanente s SanDiego Health Appraisal Clinic. More than 45,000 adultsundergo standardized examinations there each year,making this clinic one of the nation s largest free-standing medical evaluation centers.

8 All en-rollees in the Kaiser Health Plan in SanDiego are advised through sales literatureabout the services (free for members) at theclinic; after enrollment, members are ad-vised again of its availability through new-member literature. Most members obtainappointments by self-referral; 20% are re-ferred by their health care provider. A recent review ofmembership and utilization records among Kaisermembers in San Diego continuously enrolled between1992 and 1995 showed that 81% of those 25 years andolder had been evaluated in the Health appraisals include completion of a standard-ized medical questionnaire that requests demographicand biopsychosocial information, review of organ sys-tems, previous medical diagnoses, and family medicalhistory.

9 A health care provider completes the medicalhistory, performs a physical examination, and reviewsthe results of laboratory tests with the MethodsThe ACE Study protocol was approved by the Institu-tional Review Boards of the Southern California Per-manente Medical Group (Kaiser Permanente), theEmory University School of Medicine, and the Office ofProtection from Research Risks, National Institutes ofHealth. All 13,494 Kaiser Health Plan members whocompleted standardized medical evaluations at theHealth Appraisal Clinic between August November of1995 and January March of 1996 were eligible toparticipate in the ACE Study. Those seen at the clinicduring December were not included because surveyresponse rates are known to be lower during theholiday the week after visiting the clinic, and hencehaving their standardized medical history alreadycompleted, members were mailed the ACE Studyquestionnaire that included questions about child-hood Abuse and exposure to forms of householddysfunction while growing up.

10 After second mailingsof the questionnaire to persons who did not respondto the first mailing, the response rate for the surveywas (9,508/13,494).SeerelatedCommentaryon pages 354,356, Journal of Preventive Medicine, Volume 14, Number 4A second survey wave of approximately the samenumber of patients as the first wave was conductedbetween June and October of 1997. The data for thesecond survey wave is currently being compiled foranalysis. The methods for the second mail survey wavewere identical to the first survey wave as describedabove. The second wave was done to enhance theprecision of future detailed analyses on special topicsand to reduce the time necessary to obtain precisestatistics on follow-up health events.


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