Prior research on the impact of childhood abuse and trauma has been limited in scope. Previous studies have focused mainly on single forms of adversities. Stressful life events do not occur in pure forms, and research is needed to assess effects of multiple trauma and abuse on adult health risk outcomes. The Adverse Childhood Experiences (ACE) Study examined the association between multiple childhood trauma and health outcomes in adults (Felitti et al., 1998). Questionnaires on adverse childhood experiences were mailed to 13,494 adults who completed a standardized medical evaluation in a large California HMO, with the final sample consisting of 9,508 participants. Respondents and nonrespondents did not differ concerning gender or years of education. However, respondents were older than nonrespondents and were more likely to be white.
The questionnaire assessed seven categories of adverse experiences: 1) psychological abuse; 2) physical abuse; 3) sexual abuse; 4) violence against the respondent's mother; 5) living with household members who were substance abusers; 6) living with individuals who were mentally ill or suicidal; or 7) living with individuals who had ever been imprisoned. The researchers instructed respondents to limit their responses to events that occurred during the first 18 years of life. Additional health risk factors and disease conditions used to assess adult health status were: smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, parental drug abuse, high numbers of lifetime sexual partners, a history of having a sexually transmitted disease (STD), ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis or jaundice, and any skeletal fracture.
Logistic regression was used to examine the association between adverse childhood experiences (range=0 to 7) and health outcomes controlling for significant demographic factors. Of the total sample, more than half (52%) of the respondents experienced one or more types of adverse childhood exposures, and 6.2% reported four or more exposures. Significant correlations were found among all categories of adverse childhood experiences; however, no multicollinearity existed between independent variables. Those with multiple categories of childhood exposure were more likely to have multiple health risk factors later in life.
The graded relationship among the seven categories of adverse childhood exposures and each of the adult health risk factors and diseases studied was highly significant (p<0.001) (Figure 1). These data provide evidence that adverse childhood exposure to trauma and household dysfunctions are significantly associated with negative health outcomes in adults. Clearly, these issues warrant further study utilizing longitudinal designs.
Public Health Care Implications for Children
Although this study is limited by its use of retrospective data, these findings have several important public health care implications for children exposed to trauma. Appropriate interventions could potentially address major health issues, such as drug abuse, depression, suicide attempts, STDs, obesity, ischemic heart disease and cancer, which sometimes occur in adult survivors of childhood trauma and abuse. These findings call for public health care interventions at the primary, secondary and tertiary levels.
Preventive programs need to target homes that are at high risk for family violence and dysfunction and where children are at an increased risk for exposure to abuse or trauma. Practitioners need to engage these individuals and their families in comprehensive home assessments and structured interventions that are aimed toward promoting more adaptive family functioning. Entire communities need to be educated regarding the potential harmful effects of prolonged exposure to family dysfunction and childhood trauma. Parental support groups, affordable day care services and greater access to community resources need to be offered to caretakers to reduce family disintegration and cumulative stress. Caretakers also need to be guided in connecting with their natural helping networks that will allow them to share child care responsibilities (reducing parental isolation) and modify harmful parenting practices that perpetuate increased exposure to family trauma.
Children exposed to ongoing trauma at home need to be correctly assessed by trained public and mental health care practitioners to circumvent further possible psychological, behavioral and physical decline. Symptoms of chronic exposure to trauma include a lifetime history of major depressive disorders, alcohol/drug use/dependency and anxiety disorders (Briere and Runtz, 1990). Symptoms of hypervigilance and increased antisocial behaviors in children may be incorrectly attributed solely to attention-deficit/hyperactivity disorder and other behavioral diagnoses. Skillful assessments and interventions are treatment imperatives for children exposed to violence and disruption at home. Public health care workers should facilitate and encourage enrollment in drug treatment, primary care and mental health care programs for individuals exposed to chronic trauma who show early signs of drug use and poor biopsychosocial functioning.
The developmental and behavioral consequences of repeated exposure to violence call for an effective assessment response by mental health care professionals. Curtailing poor health outcomes in adults requires a thorough assessment for family dysfunction and individual trauma in children. Such behaviors may manifest as extreme hopelessness or fatalistic behaviors later in life.
We contend that evidence-based prevention strategies could prevent exposure to adverse childhood experiences or ameliorate the poor health and mental health outcomes of being exposed to adverse childhood experiences (Henggeler et al., 1992; Olds et al., 1998). Prevention strategies need to be nested within a comprehensive mental health care and wellness infrastructure to have effectiveness and wide dissemination.
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