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The Adverse Childhood Experiences Study was designed to describe the long-term relationship of household conditions, neglect, abuse, sexual and physical maltreatment of children on their adult disease risk factors, quality of life, health-care use, and mortality. The ACE study was conducted during a seven-month period at Kaiser Permanente's San Diego Health Appraisal Clinic.

After visiting the clinic for a standardized medical evaluation, all 13,494 patients were mailed the ACE questionnaire (response rate 71%). Risk-factor screening items were taken from the Centers for Disease Control and Prevention Behavioral Risk Factor Survey program, the Third National Health and Nutrition Examination Survey, and the Diagnostic Interview Schedule depression measure developed by NIMH. Disease conditions were assessed from medical histories. The categories of childhood exposure were assessed by multi-item standardized measures tapping psychological, physical, and sexual abuse; and household dysfunction including substance abuse, mental illness, criminal behavior, and violence against the respondent's mother by anyone living in the home.

Results showed that both the prevalence and risk measured by adjusted odds ratio increased for smoking, severe obesity, physical activity, depressed mood, and suicidal attempts as the number of different forms of adverse childhood experiences increased. These are the risk factors underlying the leading causes of death. Strong evidence of clustering of these risk factors was found. Whereas 56% of those with no childhood exposures had none of the 10 risk factors, only 14% of those with four or more forms of adverse childhood exposures had none. Among persons with 4 or more risk factors, the odds ratios for the presence of disease were elevated, ranging from 1.6 for diabetes to 3.9 for chronic bronchitis or emphysema. A significant dose-response relationship was found between the number of childhood exposures and each of the risk factors for the leading causes of death (p < .001). Likewise, there was a strong dose-response relationship between exposures and diseases including ischemic heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures, and poor self-rated health (p < .05). However, these are associations based on retrospective, self-report and subject to all the limitations inherent in this data source.

The findings suggest hazardous health behaviors used as coping devices in the face of household stress may be among the mediators linking adverse childhood exposures to deleterious health outcomes. The positive neuroregulatory effects of health-risk behaviors such as smoking provide biobehavioral explanations for a link between adverse experiences and disease. The article enumerates prevention strategies at the primary, secondary, and tertiary levels aimed at reducing mortality linked to adverse childhood environments. The authors conclude, "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" (p. 256).


Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & 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 Study. Am J Prev Med 14: 245­258.