The Adverse Childhood Experiences (ACEs) Study:

A summary

[ Summary by Charles L. Whitfield MD ]

Felitti VJ, Anda RF, Nordenberg D et al: The relationship of adult health status to childhood abuse & household dysfunction. American Journal of Preventive Medicine 14(4):245-258, May 1998

This important study was conducted on a large number of people (9,508 respondents of 13,494 [70.5%]). These were adults who were recently medically evaluated and then completed a 68 question survey about 7 categories of childhood trauma (adverse childhood experiences[ACEs]). The authors found that a large percentage of this general medical population reported the following traumatic experiences from their childhood.

1) Lived with problem drinker, alcoholic or street drug user: 25.6%

2) Sexually abused (overt abuse only): 22

3) Lived with mentally ill person: 18.8

4) Mother treated violently: 12.5

5) Emotionally abused: 11.1

6) Physically abused: 10.8

7) Household member went to prison: 3.4

Any category 52.1%(less than the total of the above due to more than one in most)


For those with up to a maximum of 4+ ACEs, the following risk factors and disease conditions were found to be substantially more common (compared to those persons with 0 ACES):

Cigarette Smokers to 2+ times (x) those with no ACEs.

IHD 2.2 x

Severe obesity 1.6 x

Cancer 1.9 x

No leisure time physical activity 1.3 x

Stroke 2.4 x

Depressed 2 weeks 4.6 x

COPD 3.9 x

Suicide attempt 12.2 x

Diabetes 1.6 x

Alcoholic 7.4 x

Broken bones 1.6 x

Illegal drug use 4.7 x

Hepatitis/jaundice 2.4 x

Injected drugs 10.3 x

Fair/poor health 2.2 x

Had an STD 2.5 x

50+ intercourse partners 3.2 x


These serious medical conditions and disorders were clearly more common (by the above numbers) than they are known to exist in the general population. Several of these are also known to occur more commonly among survivors of traumas such as child sexual abuse.

Figure 2 from this study is worth studying, and is reproduced here. I have also included another version of Fig. 2 that I made after reading the ACE study before I saw it.


This study is ongoing and will assess the health status of study participants including incidence of major diseases, effect of ACEs on longevity, and the costs and utilization of health care.

Thoughtful editorial commentaries on this study are in this issue of AJPM by William Foege (p354-5), M Weiss & S Wagner (p356-60), and Charles Whitfield (p 361-4).


Two Other Studies Show Similar Results

McCauley J, Kern DE, Kolodner K et al: Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 277 (17): 1362-1368, l997

Here, 424 of 1,931 women surveyed (22%) reported physical or sexual abuse during childhood or adolescence. When compared to the 88% who did not so report, those with abuse histories had more: physical symptoms (p<.001) and higher scores for : depression, anxiety (fear), somatization (physical symptoms and problems) and low self-esteem (p<.001), and more likely to: abuse drugs+/or alcohol, have attempted suicide, have a psychiatric hospital admission, have difficulty in relationships and less likely to be married. Half of those abused as children reported being abused as adults.

Limitations: used only two screening questions for childhood abuse.

Many similarities to above & below study...

The other study, as yet not published, though no less valuable, is:

Walker E, Koss M, Bernstein D et al: Long-term medical outcomes of women with childhood sexual, physical or emotional victimization. Preliminary data, 1997.

1,000 + women, ages 18-45, in a Seattle HMO, completed a 22 page survey.

1) No history of child abuse: 154= 25% (n = from first 620 of the 1,000)
    Subthreshold abuse 226= 36

2) Physical &/or psychological abuse: 92= 15 +

3) Sexual abuse: 148= 24 = 39%

Child abuse was associated with : 1) worse self-rating of health, 2) increased: * illness, * doctor office visits, * functional disability, * sexual and OB/GYN problems, *somatization, * dangerous risk taking (e.g. drinking and driving, alcohol abuse, smoking, not using seat belts, unprotected sex, promiscuity, overweight), and * current medical symptoms.

These physical symptoms and disorders are * easier recognized by physicians and nurses and * may be better clues to early childhood abuse and neglect than psychological symptoms and disorders.


This study is ongoing and will be expanded. Preliminary data show that the cost to the HMO/patients is significantly higher for those patients with abuse histories than those without. These data may help HMOs understand that it is more cost effective in the long run to pay for longer term treatment, e.g. in group and individual therapy, than not.

Comment on the ACE & other studies: Whitfield CL: Adverse childhood experience and trauma (editorial). American Journal of Preventive Medicine, 14(4):361-364, May, 1998

I summarize many other similar and supporting studies in The Truth about Depression and The Truth about Mental Illness.