7 Trauma Related Articles Needed / Minimum 1 Page Each!
2 research articles are required every week. Research articles must be sent via email to instructor no later than Friday at 6:00 pm.
Brief Summary of the class syllabus:
PSYC 4606-01 Adverse Childhood Experiences & Historical Trauma. This course is an introduction to the study of adverse childhood experiences (ACES) and its implications for the fields of social work, education, epigenetics, medical/health sciences and psychology. Emphasis is placed on the 10 categories of adverse childhood experiences and how the stress and trauma of adversity can be transferred through generations. This course is an intensive study of the impact that historical, collective and racial trauma have on physical health, psychological and societal outcomes.
Basically the instructor wants two articles every week I was not informed however she has allowed me to turn in what I’ve missed I need 7 articles 1 page in length each or more related to or dealing with trauma in children mostly. Below is the Aces Study you can use if need be but mostly you are picking the topic yourself and doing a small little research paper on it be sure to site the website you get your info from. I need 7 DIFFERENT article research papers. 7 DIFFERENT!
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
Vincent 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, MPH
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.
Medical Subject Headings (MeSH): child abuse, sexual, domestic violence, spouse abuse,
children of impaired parents, substance abuse, alcoholism, smoking, obesity, physical
activity, depression, suicide, sexual behavior, sexually transmitted diseases, chronic obstruc-
tive pulmonary disease, ischemic heart disease. (Am J Prev Med 1998;14:245258) 1998
American Journal of Preventive Medicine
Department of Preventive Medicine, Southern California Perma-
nente Medical Group (Kaiser Permanente), (Felitti) San Diego,
California 92111. National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention,
(Anda, Williamson, Spitz, Edwards, Marks) Atlanta, Georgia 30333.
Department 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 85727.
Address correspondence to: Vincent J. Felitti, MD, Kaiser Perma-
nente, Department of Preventive Medicine, 7060 Clairemont Mesa
Boulevard, San Diego, California 92111.
245Am J Prev Med 1998;14(4) 0749-3797/98/$19.00
1998 American Journal of Preventive Medicine PII S0749-3797(98)00017-8
Introduction
Only recently have medical investigators in pri-mary care settings begun to examine associa-tions between childhood abuse and adult
health risk behaviors and disease.15 These associations
are important because it is now clear that the leading
causes of morbidity and mortality in the United States6
are related to health behaviors and lifestyle factors;
these factors have been called the actual causes of
death.7 Insofar as abuse and other potentially
damaging childhood experiences contribute
to the development of these risk factors, then
these childhood exposures should be recog-
nized as the basic causes of morbidity and
mortality in adult life.
Although sociologists and psychologists
have published numerous articles about the
frequency8 12 and long-term consequenc-
es1315 of childhood abuse, understanding their rele-
vance to adult medical problems is rudimentary. Fur-
thermore, medical research in this field has limited
relevance to most primary care physicians because it is
focused on adolescent health,16 20 mental health in
adults,20 or on symptoms among patients in specialty
clinics.22,23 Studies of the long-term effects of child-
hood abuse have usually examined single types of abuse,
particularly sexual abuse, and few have assessed the im-
pact of more than one type of abuse.5,24 28 Conditions
such as drug abuse, spousal violence, and criminal activity
in the household may co-occur with specific forms of
abuse that involve children. Without measuring these
household factors as well, long-term influence might be
wrongly attributed solely to single types of abuse and
the cumulative influence of multiple categories of
adverse childhood experiences would not be assessed.
To our knowledge, the relationship of adult health risk
behaviors, health status, and disease states to childhood
abuse and household dysfunction29 35 has not been
described.
We undertook the Adverse Childhood Experiences
(ACE) Study in a primary care setting to describe the
long-term relationship of childhood experiences to
important medical and public health problems. The
ACE Study is assessing, retrospectively and prospec-
tively, the long-term impact of abuse and household
dysfunction during childhood on the following out-
comes in adults: disease risk factors and incidence,
quality of life, health care utilization, and mortality. In
this initial paper we use baseline data from the study to
provide an overview of the prevalence and interrelation
of exposures to childhood abuse and household dys-
function. We then describe the relationship between
the number of categories of these deleterious child-
hood exposures and risk factors and those diseases that
underlie many of the leading causes of death in
adults.6,7,36,37
Methods
Study Setting
The ACE Study is based at Kaiser Permanentes San
Diego Health Appraisal Clinic. More than 45,000 adults
undergo standardized examinations there each year,
making this clinic one of the nations largest free-
standing medical evaluation centers. All en-
rollees in the Kaiser Health Plan in San
Diego are advised through sales literature
about the services (free for members) at the
clinic; after enrollment, members are ad-
vised again of its availability through new-
member literature. Most members obtain
appointments by self-referral; 20% are re-
ferred by their health care provider. A recent review of
membership and utilization records among Kaiser
members in San Diego continuously enrolled between
1992 and 1995 showed that 81% of those 25 years and
older had been evaluated in the Health Appraisal
Clinic.
Health appraisals include completion of a standard-
ized medical questionnaire that requests demographic
and biopsychosocial information, review of organ sys-
tems, previous medical diagnoses, and family medical
history. A health care provider completes the medical
history, performs a physical examination, and reviews
the results of laboratory tests with the patient.
Survey Methods
The ACE Study protocol was approved by the Institu-
tional Review Boards of the Southern California Per-
manente Medical Group (Kaiser Permanente), the
Emory University School of Medicine, and the Office of
Protection from Research Risks, National Institutes of
Health. All 13,494 Kaiser Health Plan members who
completed standardized medical evaluations at the
Health Appraisal Clinic between AugustNovember of
1995 and JanuaryMarch of 1996 were eligible to
participate in the ACE Study. Those seen at the clinic
during December were not included because survey
response rates are known to be lower during the
holiday period.38
In the week after visiting the clinic, and hence
having their standardized medical history already
completed, members were mailed the ACE Study
questionnaire that included questions about child-
hood abuse and exposure to forms of household
dysfunction while growing up. After second mailings
of the questionnaire to persons who did not respond
to the first mailing, the response rate for the survey
was 70.5% (9,508/13,494).
See
related
Commentary
on pages 354,
356, 361.
246 American Journal of Preventive Medicine, Volume 14, Number 4
A second survey wave of approximately the same
number of patients as the first wave was conducted
between June and October of 1997. The data for the
second survey wave is currently being compiled for
analysis. The methods for the second mail survey wave
were identical to the first survey wave as described
above. The second wave was done to enhance the
precision of future detailed analyses on special topics
and to reduce the time necessary to obtain precise
statistics on follow-up health events. An overview of the
total ACE Study design is provided in Figure 1.
Comparison of
Respondents and Nonrespondents
We abstracted the completed medical evaluation for
every person eligible for the study; this included their
medical history, laboratory results, and physical find-
ings. Respondent (n 5 9,508) and nonrespondent
(n 5 3,986) groups were similar in their percentages
of women (53.7% and 51.0%, respectively) and in their
mean years of education (14.0 years and 13.6 years,
respectively). Respondents were older than nonrespon-
dents (means 56.1 years and 49.3 years) and more likely
to be white (83.9% vs. 75.3%) although the actual
magnitude of the differences was small.
Respondents and nonrespondents did not differ with
regard to their self-rated health, smoking, other sub-
stance abuse, or the presence of common medical
conditions such as a history of heart attack or stroke,
chronic obstructive lung disease, hypertension, or dia-
betes, or with regard to marital status or current family,
marital, or job-related problems (data not shown). The
health appraisal questionnaire used in the clinic con-
tains a single question about childhood sexual abuse
that reads As a child were you ever raped or sexually
molested? Respondents were slightly more likely to
answer affirmatively than nonrespondents (6.1% vs.
5.4%, respectively).
Questionnaire Design
We used questions from published surveys to construct
the ACE Study questionnaire. Questions from the Con-
flicts Tactics Scale39 were used to define psychological
and physical abuse during childhood and to define
violence against the respondents mother. We adapted
four questions from Wyatt40 to define contact sexual
abuse during childhood. Questions about exposure to
alcohol or drug abuse during childhood were adapted
from the 1988 National Health Interview Survey.41 All
of the questions we used in this study to determine
childhood experiences were introduced with the
phrase While you were growing up during your first 18
years of life . . .
Questions about health-related behaviors and health
problems were taken from health surveys such as the
Behavioral Risk Factor Surveys42 and the Third Na-
tional Health and Nutrition Examination Survey,43
both of which are directed by the Centers for Disease
Control and Prevention. Questions about depression
came from the Diagnostic Interview Schedule of the
National Institute of Mental Health (NIMH).44 Other
information for this analysis such as disease history was
obtained from the standardized questionnaire used in
the Health Appraisal Clinic. (A copy of the question-
naires used in this study may be found at www.elsevier.
com/locate/amepre.)
Figure 1. ACE Study design. *After exclusions, 59.7% of the original wave I sample (8,056/13,494) were included in this analysis.
Am J Prev Med 1998;14(4) 247
Defining Childhood Exposures
We used three categories of childhood abuse: psycho-
logical abuse (2 questions), physical abuse (2 ques-
tions), or contact sexual abuse (4 questions). There
were four categories of exposure to household dysfunc-
tion during childhood: exposure to substance abuse
(defined by 2 questions), mental illness (2 questions),
violent treatment of mother or stepmother (4 ques-
tions), and criminal behavior (1 question) in the house-
hold. Respondents were defined as exposed to a cate-
gory if they responded yes to 1 or more of the
questions in that category. The prevalence of positive
responses to the individual questions and the category
prevalences are shown in Table 1.
We used these 7 categories of childhood exposures to
abuse and household dysfunction for our analysis. The
measure of childhood exposure that we used was simply
the sum of the categories with an exposure; thus the
possible number of exposures ranged from 0 (unex-
posed) to 7 (exposed to all categories).
Risk Factors and Disease Conditions Assessed
Using information from both the study questionnaire
and the Health Appraisal Clinics questionnaire, we
chose 10 risk factors that contribute to the leading
causes of morbidity and mortality in the United
States.6,7,36,37 The risk factors included smoking, severe
obesity, physical inactivity, depressed mood, suicide
attempts, alcoholism, any drug abuse, parenteral drug
abuse, a high lifetime number of sexual partners
($50), and a history of having a sexually transmitted
disease.
We also assessed the relationship between childhood
exposures and disease conditions that are among the
leading causes of mortality in the United States.6 The
presence of these disease conditions was based upon
medical histories that patients provided in response to
the clinic questionnaire. We included a history of
ischemic heart disease (including heart attack or use of
nitroglycerin for exertional chest pain), any cancer,
stroke, chronic bronchitis, or emphysema (COPD),
Table 1. Prevalence of childhood exposure to abuse and household dysfunction
Category of childhood exposurea Prevalence (%) Prevalence (%)
Abuse by category
Psychological 11.1
(Did a parent or other adult in the household . . .)
Often or very often swear at, insult, or put you down? 10.0
Often or very often act in a way that made you afraid that
you would be physically hurt?
4.8
Physical 10.8
(Did a parent or other adult in the household . . .)
Often or very often push, grab, shove, or slap you? 4.9
Often or very often hit you so hard that you had marks or
were injured?
9.6
Sexual 22.0
(Did an adult or person at least 5 years older ever . . .)
Touch or fondle you in a sexual way? 19.3
Have you touch their body in a sexual way? 8.7
Attempt oral, anal, or vaginal intercourse with you? 8.9
Actually have oral, anal, or vaginal intercourse with you? 6.9
Household dysfunction by category
Substance abuse 25.6
Live with anyone who was a problem drinker or alcoholic? 23.5
Live with anyone who used street drugs? 4.9
Mental illness 18.8
Was a household member depressed or mentally ill? 17.5
Did a household member attempt suicide? 4.0
Mother treated violently 12.5
Was your mother (or stepmother)
Sometimes, often, or very often pushed, grabbed, slapped,
or had something thrown at her?
11.9
Sometimes, often, or very often kicked, bitten, hit with a
fist, or hit with something hard?
6.3
Ever repeatedly hit over at least a few minutes? 6.6
Ever threatened with, or hurt by, a knife or gun? 3.0
Criminal behavior in household
Did a household member go to prison? 3.4 3.4
Any category reported 52.1%
aAn exposure to one or more items listed under the set of questions for each category.
248 American Journal of Preventive Medicine, Volume 14, Number 4
diabetes, hepatitis or jaundice, and any skeletal frac-
tures (as a proxy for risk of unintentional injuries). We
also included responses to the following question about
self-rated health: Do you consider your physical health
to be excellent, very good, good, fair, or poor? because
it is strongly predictive of mortality.45
Definition of Risk Factors
We defined severe obesity as a body mass index (kg/
meter2) $35 based on measured height and weight;
physical inactivity as no participation in recreational
physical activity in the past month; and alcoholism as a
Yes response to the question Have you ever consid-
ered yourself to be an alcoholic? The other risk factors
that we assessed are self-explanatory.
Exclusions from Analysis
Of the 9,508 survey respondents, we excluded 51
(0.5%) whose race was unstated and 34 (0.4%) whose
educational attainment was not reported. We also ex-
cluded persons who did not respond to certain ques-
tions about adverse childhood experiences. This in-
volved the following exclusions: 125 (1.3%) for
household substance abuse, 181 (1.9%) for mental
illness in the home, 148 (1.6%) for violence against
mother, 7 (0.1%) for imprisonment of a household
member, 109 (1.1%) for childhood psychological
abuse, 44 (0.5%) for childhood physical abuse, and 753
(7.9%) for childhood sexual abuse. After these exclu-
sions, 8,056 of the original 9,508 survey respondents
(59.7% of the original sample of 13,494) remained and
were included in the analysis. Procedures for insuring
that the findings based on complete data were gener-
alizable to the entire sample are described below.
The mean age of the 8,506 persons included in this
analysis was 56.1 years (range: 19 92 years); 52.1% were
women; 79.4% were white. Forty-three percent had
graduated from college; only 6.0% had not graduated
from high school.
Statistical Analysis
We used the Statistical Analysis System (SAS)46 for our
analyses. We used the direct method to age-adjust the
prevalence estimates. Logistic regression analysis was
employed to adjust for the potential confounding ef-
fects of age, sex, race, and educational attainment on
the relationship between the number of childhood
exposures and health problems.
To test for a dose-response relationship to health
problems, we entered the number of childhood expo-
sures as a single ordinal variable (0, 1, 2, 3, 4, 5, 6, 7)
into a separate logistic regression model for each risk
factor or disease condition.
Assessing the Possible Influence of Exclusions
To determine whether our results were influenced by
excluding persons with incomplete information on any
of the categories of childhood exposure, we performed
a separate sensitivity analysis in which we included all
persons with complete demographic information but
assumed that persons with missing information for a
category of childhood exposure did not have an expo-
sure in that category.
Results
Adverse Childhood Exposures
The level of positive responses for the 17 questions
included in the seven categories of childhood exposure
ranged from 3.0% for a respondents mother (or
stepmother) having been threatened with or hurt by a
gun or knife to 23.5% for having lived with a problem
drinker or alcoholic (Table 1). The most prevalent of
the 7 categories of childhood exposure was substance
abuse in the household (25.6%); the least prevalent
exposure category was evidence of criminal behavior in
the household (3.4%). More than half of respondents
(52%) experienced $1 category of adverse childhood
exposure; 6.2% reported $4 exposures.
Relationships between
Categories of Childhood Exposure
The probability that persons who were exposed to any
single category of exposure were also exposed to an-
other category is shown in Table 2. The relationship
between single categories of exposure was significant
for all comparisons (P , .001; chi-square). For persons
reporting any single category of exposure, the proba-
bility of exposure to any additional category ranged
from 65%93% (median: 80%); similarly, the probabil-
ity of $2 additional exposures ranged from 40%74%
(median: 54.5%).
The number of categories of childhood exposures by
demographic characteristics is shown in Table 3. Statis-
tically, significantly fewer categories of exposure were
found among older persons, white or Asian persons,
and college graduates (P , .001). Because age is
associated with both the childhood exposures as well as
many of the health risk factors and disease outcomes,
all prevalence estimates in the tables are adjusted for
age.
Relationship between
Childhood Exposures and Health Risk Factors
Both the prevalence and risk (adjusted odds ratio)
increased for smoking, severe obesity, physical inactiv-
ity, depressed mood, and suicide attempts as the num-
ber of childhood exposures increased (Table 4). When
Am J Prev Med 1998;14(4) 249
persons with 4 categories of exposure were compared
to those with none, the odds ratios ranged from 1.3 for
physical inactivity to 12.2 for suicide attempts (Table 4).
Similarly, the prevalence and risk (adjusted odds
ratio) of alcoholism, use of illicit drugs, injection of
illicit drugs, $50 intercourse partners, and history of a
sexually transmitted disease increased as the number of
childhood exposures increased (Table 5). In compar-
ing persons with $4 childhood exposures to those with
none, odds ratios ranged from 2.5 for sexually trans-
mitted diseases to 7.4 for alcoholism and 10.3 for
injected drug use.
Childhood Exposures and
Clustering of Health Risk Factors
We found a strong relationship between the number of
childhood exposures and the number of health risk
factors for leading causes of death in adults (Table 6).
For example, among persons with no childhood expo-
sures, 56% had none of the 10 risk factors whereas only
14% of persons with $4 categories of childhood expo-
sure had no risk factors. By contrast, only 1% of persons
with no childhood exposures had four or more risk
factors, whereas 7% of persons with $4 childhood
exposures had four or more risk factors (Table 6).
Relationship between
Childhood Exposures and Disease Conditions
When persons with 4 or more categories of childhood
exposure were compared to those with none, the
odds ratios for the presence of studied disease con-
ditions ranged from 1.6 for diabetes to 3.9 for
chronic bronchitis or emphysema (Table 7). Simi-
larly, the odds ratios for skeletal fractures, hepatitis
or jaundice, and poor self-rated health were 1.6, 2.3,
and 2.2, respectively (Table 8).
Significance of Dose-Response Relationships
In logistic regression models (which included age,
gender, race, and educational attainment as covariates)
we found a strong, dose-response relationship between
the number of childhood exposures and each of the 10
risk factors for the leading causes of death that we
studied (P , .001). We also found a significant (P ,
.05) dose-response relationship between the number
of childhood exposures and the following disease con-
ditions: ischemic heart disease, cancer, chronic bron-
chitis or emphysema, history of hepatitis or jaundice,
skeletal fractures, and poor self-rated health. There was
no statistically significant dose-response relationship
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250 American Journal of Preventive Medicine, Volume 14, Number 4
Assessment of the Influence of Exclusions
In the sensitivity analysis where missing information for
a category of childhood exposure was considered as no
exposure, the direction and strength of the associations
between the number of childhood exposures and the
risk factors and disease conditions were nearly identical
(data not shown). Thus, the results we present appear
to be unaffected by our decision to exclude persons for
whom information on any category of childhood expo-
sure was incomplete.
Discussion
We found a strong dose response relationship between
the breadth of exposure to abuse or household dysfunc-
tion during childhood and multiple risk factors for
several of the leading causes of death in adults. Disease
conditions including ischemic heart disease, cancer,
chronic lung disease, skeletal fractures, and liver dis-
ease, as well as poor self-rated health also showed a
graded relationship to the breadth of childhood expo-
sures. The findings suggest that the impact of these
adverse childhood experiences on adult health status is
strong and cumulative.
The clear majority of patients in our study who were
exposed to one category of childhood abuse or house-
hold dysfunction were also exposed to at least one
other. Therefore, researchers trying to understand the
long-term health implications of childhood abuse may
benefit from considering a wide range of related ad-
verse childhood exposures. Certain adult health out-
comes may be more strongly related to unique combi-
nations or the intensity of adverse childhood exposures
than to the total breadth of exposure that we used for
our analysis. However, the analysis we present illustrates
the need for an overview of the net effects of a group of
complex interactions on a wide range of health risk
behaviors and diseases.
Several potential limitations need to be considered
when interpreting the results of this study. The data
about adverse childhood experiences are based on
self-report, retrospective, and can only demonstrate
associations between childhood exposures and health
risk behaviors, health status, and diseases in adulthood.
Second, some persons with health risk behaviors or
diseases may have been either more, or less, likely to
report adverse childhood experiences. Each of these
issues potentially limits inferences about causality. Fur-
thermore, disease conditions could be either over- or
under-reported by patients when they complete the
medical questionnaire. In addition, there may be me-
diators of the relationship between childhood experi-
ences and adult health status other than the risk factors
we examined. For example, adverse childhood experi-
ences may affect attitudes and behaviors toward health
and health care, sensitivity to internal sensations, or
physiologic functioning in brain centers and neuro-
transmitter systems. A more complete understanding
of these issues is likely to lead to more effective ways
to address the long-term health problems associated
with childhood abuse and household dysfunction.
However, our estimates of the prevalence of child-
Table 3. Prevalence of categories of adverse childhood exposures by demographic characteristics
Characteristic
Sample size
(N)
Number of categories (%)a
0 1 2 3 4
Age group (years)
1934 807 35.4 25.4 17.2 11.0 10.9
3549 2,063 39.3 25.1 15.6 9.1 10.9
5064 2,577 46.5 25.2 13.9 7.9 6.6
$65 2,610 60.0 24.5 8.9 4.2 2.4
Genderb
Women 4,197 45.4 24.0 13.4 8.7 8.5
Men 3,859 53.7 25.8 11.6 5.0 3.9
Raceb
White 6,432 49.7 25.3 12.4 6.7 6.0
Black 385 38.8 25.7 16.3 12.3 7.0
Hispanic 431 42.9 24.9 13.7 7.4 11.2
Asian 508 66.0 19.0 9.9 3.4 1.7
Other 300 41.0 23.5 13.9 9.5 12.1
Educationb
No HS diploma 480 56.5 21.5 8.4 6.5 7.2
HS graduate 1,536 51.6 24.5 11.3 7.4 5.2
Any college 2,541 44.1 25.5 14.8 7.8 7.8
College graduate 3,499 51.4 25.1 12.1 6.1 5.3
All participants 8,056 49.5 24.9 12.5 6.9 6.2
aThe number of categories of exposure was simply the sum of each of the seven individual categories that were assessed (see Table 1).
bPrevalence estimates adjusted for age.
Am J Prev Med 1998;14(4) 251
hood exposures are similar to estimates from nationally
representative surveys, indicating that the experiences
of our study participants are comparable to the larger
population of U.S. adults. In our study, 23.5% of
participants reported having grown up with an alcohol
abuser; the 1988 National Health Interview Survey
estimated that 18.1% of adults had lived with an alcohol
abuser during childhood.41 Contact sexual abuse was
reported by 22% of respondents (28% of women and
16% of men) in our study. A national telephone survey
of adults in 1990 using similar criteria for sexual abuse
estimated that 27% of women and 16% of men had
been sexually abused.12
There are several reasons to believe that our esti-
mates of the long-term relationship between adverse
childhood experiences and adult health are conserva-
tive. Longitudinal follow-up of adults whose childhood
abuse was well documented has shown that their retro-
spective reports of childhood abuse are likely to under-
estimate actual occurrence.47,48 Underestimates of
childhood exposures would result in downwardly bi-
ased estimates of the relationships between childhood
exposures and adult health risk behaviors and dis-
eases. Another potential source of underestimation
of the strength of these relationships is the lower
number of childhood exposures reported by older
persons in our study. This may be an artifact caused
by premature mortality in persons with multiple
adverse childhood exposures; the clustering of mul-
tiple risk factors among persons with multiple child-
hood exposures is consistent with this hypothesis.
Thus, the true relationships between adverse child-
hood exposures and adult health risk behaviors,
health status, and diseases may be even stronger than
those we report.
An essential question posed by our observations is,
Exactly how are adverse childhood experiences linked
to health risk behaviors and adult diseases? The link-
Table 4. Number of categories of adverse childhood exposure and the adjusted odds of risk factors includ
