Research articleAdverse Childhood Experiences and the Risk of Premature Mortality
Introduction
The Adverse Childhood Experiences (ACE) Study, a collaborative effort between Kaiser Permanente (San Diego CA) and the CDC (Atlanta GA), was designed to examine the long-term relationship between ACEs and a variety of health behaviors and health outcomes in adulthood.1 The ACE Study proposes that stressful or traumatic childhood experiences have negative neurodevelopmental impacts that lead through life pathways and increase the risk of a variety of behavioral, health, and social problems. The ACE pyramid is used to depict this concept (www.cdc.gov/nccdphp/ace/pyramid.htm). The seminal paper of the ACE Study1 described associations between the number of categories of ACEs and prevalent cases of disease that underlie many of the leading causes of death in the U.S. Relationships have since been reported between ACEs and numerous health-risk behaviors, health outcomes, healthcare utilization, and health status.2 A case–control study3 conducted in Washington State described an increased risk of death prior to age 18 years among substantiated cases of child abuse relative to a comparison population, whereas a study of substantiated cases of abuse and matched neighborhood controls reported no association between abuse and mortality in young adulthood.4 On the basis of this evidence, a prospective cohort study of 16,908 adults was initiated to assess the relationship between the cumulative effects of ACEs and premature mortality.
Section snippets
Methods
The ACE Study is based at Kaiser Permanente's San Diego Health Appraisal Clinic, a primary care clinic where more than 50,000 adult members of the Kaiser Permanente HMO receive an annual, standardized, biopsychosocial medical examination.5 Each member who visits the Health Appraisal Clinic completes a standardized medical questionnaire.1 The medical history is completed by a healthcare provider who also performs a general physical exam and reviews laboratory test results with the patient.1
Results
Responses to the eight individual ACE components varied by age such that a higher proportion of participants aged <65 years reported ACEs and had higher ACE scores than respondents aged ≥65 years at baseline (Table 1). However, the overall prevalence of ACEs was high, with one or more ACEs reported by 69.1% of participants aged <65 years and by 53.0% of those aged ≥65 years.
The frequency of deaths from all causes and mortality rates by selected study participant characteristics are shown for
Discussion
In this prospective cohort study, people exposed to multiple childhood traumatic stressors captured in the ACE score were at increased risk of premature death compared to people without ACEs. In contrast to prior ACE Study analyses demonstrating strong, graded relationships between the ACE score and a variety of health behaviors and health outcomes, a graded increase was not observed in the risk of premature death across the number of categories of ACEs. For nearly all measures, the analysis
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