Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study.

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.

Cumulative childhood stress and autoimmune diseases in adults.

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.

The relationship of adverse childhood experiences to a history of premature death of family members.

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.

Health Appraisal and the Adverse Childhood Experiences Study: National Implications for Health Care, Cost, and Utilization.

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.

REPRINT OF: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study.

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.

Adverse childhood experiences and chronic obstructive pulmonary disease in adults.

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.

Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients.

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.

Self-reported information and pharmacy claims were comparable for lipid-lowering medication exposure.

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.

Adverse childhood experiences and prescribed psychotropic medications in adults.

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.

Adverse childhood experiences and childhood autobiographical memory disturbance.

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.

Insights into causal pathways for ischemic heart disease: adverse childhood experiences study.

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.

Childhood residential mobility and multiple health risks during adolescence and adulthood: the hidden role of adverse childhood experiences.

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.

Long-term consequences of childhood sexual abuse by gender of victim.

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.

Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway.

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.

Adverse childhood experiences and hallucinations.

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.

Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study.

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.

Adverse childhood experiences and risk of paternity in teen pregnancy.

OBJECTIVE: Few studies have investigated risk factors that predispose males to be involved in teen pregnancies. To provide new information on such factors, we examined the relationships of eight common adverse childhood experiences to a male's risk of impregnating a teenager. METHODS: We conducted a retrospective cohort study using questionnaire responses from 7399 men who visited a primary care clinic of a large health maintenance organization in California. Data included age of the youngest female ever impregnated; the man's own age at the time; his history of childhood emotional, physical, or sexual abuse; having a battered mother; parental separation or divorce; and having household members who were substance abusers, mentally ill, or criminals. Odds ratios (ORs) for the risk of involvement in a teen pregnancy were adjusted for age, race, and education. RESULTS: At least one adverse childhood experience was reported by 63% of participants, and 34% had at least two adverse childhood experiences; 19% of men had been involved in a teen pregnancy. Each adverse childhood experience was positively associated with impregnating a teenager, with ORs ranging from 1.2 (sexual abuse) to 1.8 (criminal in home). We found strong graded relationships (P <.001) between the number of adverse childhood experiences and the risk of involvement in a teen pregnancy for each of four birth cohorts during the last century. Compared with males with no adverse childhood experiences, a male with at least five adverse childhood experiences had an OR of 2.6 (95% confidence interval [CI] 2.0, 3.4) for impregnating a teenager. The magnitude of the ORs for the adverse childhood experiences was reduced 64-100% by adjustment for potential intermediate variables (age at first intercourse, number of sexual partners, having a sexually transmitted disease, and alcohol or drug abuse) that also exhibited a strong graded relationship to adverse childhood experiences. CONCLUSION: Adverse childhood experiences have an important relationship to male involvement in teen pregnancy. This relationship has persisted throughout four successive birth cohorts dating back to 1900-1929, suggesting that the effects of adverse childhood experiences transcend changing sexual mores and contraceptive methods. Efforts to prevent teen pregnancy will likely benefit from preventing adverse childhood experiences and their associated effects on male behaviors that might mediate the increased risk of teen pregnancy.

Adverse childhood experiences and the risk of depressive disorders in adulthood.

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.

Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression.

OBJECTIVE: The study examined how growing up with alcoholic parents and having adverse childhood experiences are related to the risk of alcoholism and depression in adulthood. METHODS: In this retrospective cohort study, 9,346 adults who visited a primary care clinic of a large health maintenance organization completed a survey about nine adverse childhood experiences: experiencing childhood emotional, physical, and sexual abuse; witnessing domestic violence; parental separation or divorce; and growing up with drug-abusing, mentally ill, suicidal, or criminal household members. The associations between parental alcohol abuse, the adverse experiences, and alcoholism and depression in adulthood were assessed by logistic regression analyses. RESULTS: The risk of having had all nine of the adverse childhood experiences was significantly greater among the 20 percent of respondents who reported parental alcohol abuse. The number of adverse experiences had a graded relationship to alcoholism and depression in adulthood, independent of parental alcohol abuse. The prevalence of alcoholism was higher among persons who reported parental alcohol abuse, no matter how many adverse experiences they reported. The association between parental alcohol abuse and depression was accounted for by the higher risk of having adverse childhood experiences in alcoholic families. CONCLUSIONS: Children in alcoholic households are more likely to have adverse experiences. The risk of alcoholism and depression in adulthood increases as the number of reported adverse experiences increases regardless of parental alcohol abuse. Depression among adult children of alcoholics appears to be largely, if not solely, due to the greater likelihood of having had adverse childhood experiences in a home with alcohol-abusing parents.