Only recently have medical investigators in primary care settings begun to examine associations between childhood abuse and adult health risk behaviors and disease.¹,⁵ 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 recognized 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 consequences¹³,¹⁵ of childhood abuse, understanding their relevance to adult medical problems is rudimentary. Furthermore, 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 prospectively, 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 dysfunction. 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

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³ Felitti VJ. Childhood sexual abuse, depression and family dysfunction in adult obese patients: a case control study. South Med J 1993;86:732–6.

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⁵ McCauley J, Kern DE, Kolodner K, Schroeder AF, et al. Clinical characteristics of women with a history of child-hood abuse. JAMA 1997;277:1362– 8.

⁶ Mortality patterns: United States, 1993. Morb Mortal Wkly Rep 1996;45:161– 4.

⁷ McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–12.

⁸ Landis J. Experiences of 500 children with adult sexual deviation. Psychiatr Q 1956;30(Suppl):91–109.

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¹² Finkelhor D, Hotaling G, Lewis IA, Smith C. Sexual abuse in a national survey of adult men and women: prevalence, characteristics, and risk factors. Child Abuse Negl 1990; 14:19 –28.

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¹⁵ Beitchman JH, Zucker KJ, Hood JE, DaCosta GA, Akman D, Cassavia E. A review of the long-term effects of sexual abuse. Child Abuse Negl 1992;16:101–18.

¹⁶ Hibbard RA, Ingersoll GM, Orr DP. Behavioral risk, emotional risk, and child abuse among adolescents in a nonclinical setting. Pediatrics 1990;86:896–901.

¹⁷ Nagy S, Adcock AG, Nagy MC. A comparison of risky health behaviors of sexually active, sexually abused, and abstaining adolescents. Pediatrics 1994;93:570–5.

¹⁸ Cunningham RM, Stiffman AR, Dore P. The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: implications for public health. Child Abuse Negl 1994;18:233–45.

¹⁹ Council on Scientific Affairs. Adolescents as victims of family violence. JAMA 1993;270:1850–6.

²⁰ Nelson DE, Higginson GK, Grant-Worley JA. Physical abuse among high school students. Prevalence and cor- relation with other health behaviors. Arch Pediatr Ado- lesc Med 1995;149:1254–8.

²¹. Mullen PE, Roman-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women’s mental health. Lancet 1988;1:841–5.

²². DrossmanDA,LesermanJ,NachmanG,LiZ,etal.Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990;113: 828 –33.

²³ Harrop-Griffiths J, Katon W, Walker E, Holm L, Russo J, Hickok L. The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse. Ob- stet Gynecol 1988;71:589–94.

²⁴ Briere J, Runtz M. Multivariate correlates of childhood psychological and physical maltreatment among university women. Child Abuse Negl 1988;12:331– 41.

²⁵ Briere J, Runtz M. Differential adult symptomatology associated with three types of child abuse histories. Child Abuse Negl 1990;14:357– 64.

²⁶ Claussen AH, Crittenden PM. Physical and psychological maltreatment: relations among types of maltreatment. Child Abuse Negl 1991;15:5–18.

²⁷ Moeller TP, Bachman GA, Moeller JR. The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse Negl 1993;17:623– 40.

²⁸ Bryant SL, Range LM. Suicidality in college women who were sexually and physically punished by parents. Vio- lence Vict 1995;10:195–201.

²⁹ Zeitlen H. Children with alcohol misusing parents. Br Med Bull 1994;50:139–51.

³⁰ Dore MM, Doris JM, Wright P. Identifying substance abuse in maltreating families: a child welfare challenge. Child Abuse Negl 1995;19:531–43.

³¹ Ethier LS, Lacharite C, Couture G. Childhood adversity, parental stress, and depression of negligent mothers. Child Abuse Negl 1995;19:619–32.

³² Spaccarelli S, Coatsworth JD, Bowden BS. Exposure to family violence among incarcerated boys; its association with violent offending and potential mediating variables. Violence Vict 1995;10:163–82.

³³ McCloskey LA, Figueredo AJ, Koss MP. The effects of systemic family violence on children’s mental health. Child Dev 1995;66:1239–61.

³⁴ Brent DA, Perper JA, Moritz G, Schweers J, Balach L, Roth C. Familial risk factors for adolescent suicide: a case-control study. Acta Psychiatr Scand 1994;89:52–8.

³⁵ Shaw DS, Vondra JI, Hommerding KD, Keenan K, Dunn M. Chronic family adversity and early child behavior problems: a longitudinal study of low income families. J Child Psychol Psychiatry 1994;35:1109–22.

³⁶ U.S. Department of Health and Human Services. Physical activity and health: A report of the Surgeon General. Atlanta, Georgia. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.

³⁷ Rivara FP, Mueller BA, Somes G, Mendoza CT, Rushforth NB, Kellerman AL. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA 1997;278:569– 75.

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