Adverse childhood exposures associated with poor health in adulthood [Pediatrics Classics Series]

Classics Series, Landmark Trials in Medicine

1. Among 8056 adult patients who completed a standardized questionnaire regarding adverse childhood exposures, a significant dose-response relationship was observed when the number of exposures were analyzed in the context of current self-reported health risk behaviors and disease states.

Original Date of Publication: May 1998

Study Rundown: At the time of this study, researchers had just begun investigating the role of childhood trauma on the development of adult medical conditions. Through a retrospective approach this study investigated the influence of childhood abuse on adult disease risk factors, disease incidence, quality of life, use of healthcare resources, and death. Overall, 8056 adults completed a standardized questionnaire addressing their exposure to various forms of adverse events including abuse and household dysfunction. Researchers found individuals who experienced adverse childhood exposures to be at increased risk of having both health-related risk factors such as smoking and obesity as well as illnesses such as ischemic heart disease and malignancy in adulthood. These risk increases were largely present in a dose-response fashion, with those who experienced more adverse exposures having higher chances of developing health risk factors and disease in adulthood when compared to those with fewer exposures. While this study was limited by its retrospective design and reliance on self-report for both adverse exposures and health status, reported prevalence of adverse exposures was consistent with national averages, implicating the potentially nationally representative nature of the study. In addition, this study provided evidence of the strong link between childhood experiences during development and the manifestation of health behaviors and disease in adulthood. These findings emphasized the importance of preventative measures starting in childhood and extending into adulthood to reduce childhood adverse exposure, the development of health risk factors, and ultimately disease development and mortality.

Click to read the study in the American Journal of Preventive Medicine

In-Depth [retrospective cohort]: A total of 8056 adults (mean age = 56.1 years, 52.1% female, 79.4% white) who underwent standardized medical evaluation at a large United States adult healthcare clinic from August-November of 1995 and January-March of 1996 and completed a study questionnaire were included. Following examination, patients received a mailed copy of the study questionnaire which inquired about childhood psychological, physical, and sexual abuse along with household dysfunction such as violence against the participant’s mother and whether or not the participant lived with individuals who engaged in substance abuse, were imprisoned, or had mental illness. Questions were derived from previously published surveys. Responses were then related to self-reported health risk factors, adult disease conditions with high mortality rates, and overall health status. Risk factors investigated included physical inactivity (defined as no physical activity participation in the past month), severe obesity (defined as body mass index > 35 kg/m2), current smoking, attempted suicide, depressed mood (defined as 2 or more weeks of depressed mood over the past year), alcohol abuse (defined as an affirmative response to the question “have you ever considered yourself to be an alcoholic?”, any illicit drug use, intravenous drug use, history of sexually transmitted infections, and high numbers of total sexual partners (defined as > 50 partners). Logistic regression analysis was completed with adjustment for potential confounders to investigate the relationship between the number of childhood exposures to risk factors and adult medical conditions.

Overall, 52% of respondents experienced > 1 adverse childhood exposure and 6.2% reported exposure to > 4 adverse events. Substance abuse was the most common adverse exposure (25.6%) with a housemate being imprisoned as the least common (3.4%). Individuals who experienced 1 adverse exposure had a median probability of exposure to at least 1 more adverse exposure of 80%. Increases in number of exposures were associated with increased odds of developing health risk factors and adult disease conditions. Linear regression accounting for age, gender, race, and educational level as covariates, revealed a significant dose-response relationship between the number of adverse childhood exposures and each of the risk factors (p < 0.001) as well as the development of ischemic heart disease, cancer, emphysema, hepatitis or jaundice, fractures, and poor health on self-report (p < 0.05). Adjusted odds ratios for developing risk factors and disease conditions based off of the number of adverse childhood exposures an individual experienced are listed in Table 1 and Table 2, respectively. Among those without any adverse childhood exposures, 56% had none of the 10 risk factors compared to 14% of those with > 4 exposures.

Table 1. Adverse childhood exposures and adjusted odds of health risk factors, adapted from Felitti et al.

Health risk factor Number of adverse exposures Adjusted odds ratio 95% confidence interval
Physical inactivity 0123

4 or more total




Severe obesity 0123

4 or more total




Current smoker 0123

4 or more total




Attempted suicide 0123

4 or more total




Depressed mood 0123

4 or more total




Alcohol abuse 0123

4 or more total




Illicit drug use 0123

4 or more total




Intravenous drug use 0123

4 or more total




History of sexually transmitted infection 0123

4 or more total




> 50 sexual partners 0123

4 or more total




Table 2. Adverse childhood exposures and adjusted odds of disease conditions, adapted from Felitti et al.

Disease condition Number of adverse exposures Adjusted odds ratio 95% confidence interval
Ischemic heart disease 0123

4 or more total




Any cancer 0123

4 or more total




Stroke 0123

4 or more total




Emphysema 0123

4 or more total




Diabetes mellitus 0123

4 or more total




Skeletal fracture at any point in time 0123

4 or more total




Hepatitis or jaundice at any  point in time 0123

4 or more total




Self-report of heath as “fair” or “poor” 0123

4 or more total




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