44

clinical contributions

The Permanente Journal/ Winter 2002/ Volume 6 No. 1

Background

The Adverse Childhood Experiences (ACE) Study is a

major research study that compares current adult health

status to childhood experiences decades earlier. With

the cooperation of 17,421 adult Health Plan members

and with the ongoing collaboration of Dr Robert Anda

at the Centers for Disease Control and Prevention (CDC),

the study is being carried out in the Department of

Preventive Medicine at Kaiser Permanente (KP) San

Diego—where for many years we conducted detailed

biomedical, psychological, and social (biopsychosocial)

evaluations of more than 50,000 adult Kaiser Foundation Health Plan members per year.

The findings are important medically, socially, and

economically: They provide remarkable insight into

how we become what we are as individuals and as a

nation. The ACE Study reveals a powerful relation

between our emotional experiences as children and

our adult emotional health, physical health, and major causes of mortality in the United States. Moreover, the time factors in the study make it clear that

time does not heal some of the adverse experiences

we found so common in the childhoods of a large

population of middle-aged, middle-class Americans.

One doesn’t “just get over” some things.

Study Design

The ACE Study was triggered by observations we

made in the mid 1980s in an obesity program at the

KP San Diego Department of Preventive Medicine. This

program then had a high dropout rate. The first of many

counterintuitive discoveries was that the great majority

of the dropouts actually were successfully losing weight.

Detailed life interviews of almost 200 such individuals

unexpectedly revealed that childhood abuse was remarkably common and antedated the onset of their

obesity. Many patients spoke openly of an association

between the two. The counterintuitive aspect was that,

for many people, obesity was not their problem; it was

their protective solution to problems that previously

had never been discussed with anyone. An early insight was the memorable remark of a woman who was

raped at age twenty-three and gained 105 pounds in

the subsequent year: “Overweight is overlooked, and

that’s the way I need to be.” The contrast was striking

between this statement and her desire to lose weight.

Similarly, two men who were guards at the State Penitentiary became anxious after losing more than 100

The Relation Between Adverse Childhood

Experiences and Adult Health: Turning Gold into Lead

By Vincent J Felitti, MD

VINCENT J FELITTI, MD, is an internist, formerly doing infectious disease work, who created and

ran, for its first 25 years, the Department of Preventive Medicine at Kaiser Permanente in San Diego.

E-mail: Vincent.J.Felitti@kp.org.

pounds each. They made it clear that they felt much

safer going to work looking “big as a refrigerator” instead of normal size. Overall, we found the simultaneous presence of opposing forces to be common; many

of our weight program patients were driving with one

foot on the brakes and one on the gas, wanting to lose

weight but fearful of change.

In 1990 in Atlanta, I presented information about

the frequent relation between obesity and abusive

childhood experiences to a largely skeptical audience

at the North American Association for the Study of

Obesity. Unexpectedly, this presentation led to contacts with researchers at the CDC, who recognized the

importance of what had been reported. They proposed

a large epidemiologic study to provide definitive evidence of our clinical observations. This was the beginning of the ACE Study at KP San Diego, where,

each year, we could easily ask more than 26,000 consecutive adults seen in the Department of Preventive

Medicine if they would be interested in helping us

understand how childhood events might affect adult

health status. Sixty-eight percent of this population

agreed to participate and understood that the information they provided about their childhood would

never be included in their medical records.

The ACE Study compared current adult health status

of these participants with eight categories of adverse

childhood experience that we had frequently identified

in the weight program. Three categories pertained to

personal abuse: recurrent physical abuse, recurrent

emotional abuse, and sexual abuse. Four categories

pertained to growing up in a dysfunctional household—

ie, with an alcoholic person or a drug user; where someone was in prison; where someone was chronically

depressed, mentally ill, or suicidal; where the mother

was treated violently; and where the parents were separated, divorced, or in some way lost to the patient during childhood. In addition, we decided to monitor this

large cohort for at least five years to compare childhood experiences prospectively against adult pharmacy

costs, doctor office visits, emergency department use,

hospitalization, and death. An ACE score was constructed

to analyze the huge mass of information we gathered.

A person exposed to none of the studied categories

had an ACE Score of 0; an individual exposed to any

four had an ACE Score of 4, etc.

Because the average study participant was 57 years

old, we actually were measuring the effect of childThe

counterintuitive

aspect was

that, for many

people, obesity

was not their

problem; it was

their protective

solution ...
45

clinical contributions

The Permanente Journal/ Winter 2002/ Volume 6 No. 1

hood experiences on adult health status a half-century later. Dr Anda, my coprincipal investigator at

CDC, designed the data management and retrospective and prospective components of the Study with great

skill. Here, I will only touch upon some highlights of

our findings; details may be sought in the anchor article of a series of publications deriving from the ACE

Study. The initial article was published in May 1998 in

the American Journal of Preventive Medicine, v 14: 245-

258;1 full text is at their Web site: www.meddevel.com/

site.mash?left=/library.exe&m1=4&m2=1&right=/

library.exe&action=search_form&search.mode=

simple&site=AJPM&jcode=AMEPRE.

A list of published peer reviewed publications from

the ACE Study is provided at the end of this article.2-11

Findings

A striking finding was that adverse childhood experiences are vastly more common than recognized

or acknowledged. Of equal importance was our observation that they had a powerful correlation to adult

health a half-century later. It is this combination that

makes them so important. Slightly more than half of

our middle-class population of Health Plan members

experienced one or more of the categories we studied. One in four was exposed to two categories of

abusive experience, one in 16 to four categories.

Given an exposure to one category, there is 80%

likelihood of exposure to another. All this, of course,

is well shielded by social taboos against obtaining

this information. Further, one may “miss the forest

for the trees” if one studies these issues individually.

They do not occur in isolation; for instance, a child

does not grow up with an alcoholic person or with

domestic violence in an otherwise well-functioning

household. The question to ask is: How will these

childhood experiences play out decades later in a

doctor’s office? How does one perform reverse alchemy, going from a normal newborn with almost

unlimited potential to a diseased, depressed adult?

How does one turn gold into lead?

Smoking is a useful starting example to illustrate

what we found; moreover, it allows us to start with a

minimally threatening topic. In California, there are

now profound social pressures against smoking; persistent smoking in the face of these is often attributed to “addiction.” But did you know that current

smoking has a high degree of association with what

happened decades ago in childhood? Figure 1 is a

graphic illustration of how the ACE Score has a graded,

dose-response effect on the probability of current

smoking. The higher the ACE Score, the greater the

likelihood of current smoking. This graded, dose-response effect is present for all the associations we

found, although I will only present three. All the relations have a p value of .001 or better. Further details

of the ACE Study findings are published in a series of

articles exploring our findings from the retrospective

and prospective arms of the Study.

Lest one doubt the significance of smoking, we found

that chronic obstructive pulmonary disease (COPD)

has a strong relationship to the ACE Score. A person

with a midrange ACE score of 4 is 390% more likely to

have COPD than is a person with an ACE Score of 0.

What does this do to the conventional concept of smoking that attributes addiction to characteristics that are

intrinsic within nicotine? We instead found “addiction”

attributable to characteristics that are intrinsic in early

life experiences. If early emotional stress predicts

COPD, is COPD properly understood as a psychosomatic condition? Are certain common, chronic, adult

diseases the result of attempts at self-treatment of concealed problems that occurred in childhood?

When we looked at self-defined current depression, we found that a person with ACE score >4 was

460% more likely to be depressed than a person with

ACE score of 0. Confirming the reliability of this conclusion, we found a 1220% historical increase in attempted suicide between these two groups. For groups

with higher ACE scores, incidence of attempted suicide increases thirtyfold to fifty-one fold! Using the

analytic technique of population attributable risk, we

0

2

4

6

8

10

12

14

16

18

20

0 1 2 3 4-5 6 or more

ACE score 

Percentage presently smoking 

Figure1. Graph shows relation between Adverse Childhood Experiences

(ACE) Score and smoking status.

... adverse

childhood

experiences

are vastly

more common

than

recognized or

acknowledged.
46

clinical contributions

The Permanente Journal/ Winter 2002/ Volume 6 No. 1

found that more than two thirds of suicide attempts

could be attributed to adverse childhood experiences.

Intravenous drug use is a major public health problem. In spite of massive efforts to curtail it, little

progress has been made. We found that IV drug use

may properly be viewed as a personal solution to

problems that are well concealed by social niceties

and convention. For example, a male child with an

ACE score of 6 has a 4600% increase in the likelihood of later using intravenous drugs. This relation

to adverse childhood experiences is powerful and is

graded at every step; it provides a perfect doseresponse curve; and epidemiologically, these outcomes are nearly unique in magnitude. Because no

one shoots heroin to get endocarditis or AIDS, might

heroin then be used for relief of profound anguish

dating back to childhood experiences? Might it be

the best coping device a person can find? If so, is this

phenomenon a public health problem or a personal

solution? How often are public health problems personal solutions? Is drug abuse self-destructive, or is it

a desperate attempt at self-healing, albeit at a significant future risk? This point is important because primary prevention is far more difficult than anticipated—possibly because incomplete understanding

of the benefits of so-called health risk behaviors

causes these behaviors to be viewed as irrational acts

that have only negative consequences. Does this incomplete view of drug abuse leave us mouthing cautionary platitudes instead of understanding the cause

of our intractable public health problems?

Beyond these few illustrations, we found many other

measures of adult health to have a strong, graded relation to what happened in childhood: hepatitis, heart

disease, fractures, diabetes, obesity, alcoholism, occupational health, and job performance. These findings

are detailed in the original and subsequent articles

and will further be reported in publications of the

yet-to-be-analyzed prospective arm of the ACE Study.

Discussion

What do these findings mean for medical practice

and for society? Clearly, we have shown that adverse

childhood experiences are both common and destructive. This combination makes them one of the

most important, if not the most important, determinants of the health and well-being of the nation. Unfortunately, these problems are both painful to recognize and difficult to cope with. Most physicians

would far rather deal with traditional organic disease. Certainly, it is easier to do so, but that approach

also leads to troubling treatment failure and to the

frustration of expensive diagnostic quandaries where

everything is ruled out but nothing is ruled in.

Our usual approach to many common adult chronic

diseases reminds one of the relation between smoke

and fire. A person unfamiliar with fires would initially be tempted to treat the smoke—ie, the most

visible aspect of the problem. What we have learned

in the ACE Study represents the underlying fire. Fortunately, fire departments learned to distinguish cause

from effect long ago; if they had not, they would use

fans instead of water hoses.

If the treatment implications of what we found in

the ACE Study are far-reaching, the prevention aspects are positively daunting. The very nature of the

material is such as to make one uncomfortable. Why

would one want to leave the relative comfort of traFigure 2. Graph shows relation between longtime smoking, chronic

obstructive pulmonary disease (COPD), and ACE Score.

Figure 3. Graph shows relation between ACE Score and illicit use

of injected drugs.

0

2

4

6

8

10

12

14

16

18

20

0 1 2 3 4 or more

ACE score

Initiated smoking by age 14 CO PD

Percentage with problem

0

0.5

1

1.5

2

2.5

3

3.5

Percentage have injected drugs 

0 1 2 3 4 or more

ACE score
47

clinical contributions

The Permanente Journal/ Winter 2002/ Volume 6 No. 1

ditional organic disease and enter this area of threatening uncertainty that none of us has been trained to

deal with? And yet, as I write these words, I am interrupted to consult on a 70-year-old woman who is diabetic and hypertensive. The initial description given

to me omitted the fact that she is morbidly obese (one

doesn’t go out of one’s way to identify what one can’t

handle). Review of her chart shows her to be chronically depressed, never married, and, because we ask

the question of 57,000 adults a year, to have been

raped by her elder brother six decades ago when she

was ten. The same brother also molested her sister,

who also is said to be leading a troubled life.

We found that 22% of our Health Plan members

were sexually abused as children. How does that affect a person later in life? What does it mean that early

sexual abuse is never spoken of? We find it useful

routinely to ask all patients acknowledging this experience, “How did that affect you later in life?”

What, then, is this woman’s diagnosis? Is she just

another hypertensive, diabetic old woman, or is there

more to the practice of medicine? Here is the way

we conceptualized her problems:

Childhood sexual abuse

Chronic depression

Morbid obesity

Diabetes mellitus

Hypertension

Hyperlipidemia

Coronary artery disease

Macular degeneration

Psoriasis

This is not a comfortable diagnostic formulation; it

points out that our attention is comfortably focused

on tertiary consequences far downstream. The diagnosis shows that the primary issues are well protected by social convention and taboo and points

out that we have limited ourselves to the smallest

part of the problem: the part where we are comfortable as mere prescribers of medication. Which diagnostic choice shall we make? Who shall make it? And

if not now, when? ❖

This article, with minor change, was originally published

in The Family Violence Prevention Fund’s “Health Alert,”

Volume 8, No. 1. Adapted and reproduced with permission

of the publisher, Peter Sawires.

Acknowledgments

The original study was funded by the US Department of

Health & Human Services; the CDC Foundation; and the

Kaiser Permanente Garfield Memorial Fund.

Selected ACE Study Publications

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of

childhood abuse and household dysfunction to many of the

leading causes of death in adults. The Adverse Childhood

Experiences (ACE) Study. Am J Prev Med 1998

May;14(4):245-58.

2. Foege WH. Adverse childhood experiences: A public health

perspective. Am J Prev Med 1998 May;14(4):354-5.

3. Weiss MJ, Wagner SH. What explains the negative

consequences of adverse childhood experiences on adult

health? Insights from cognitive and neuroscience research.

Am J Prev Med 1998 May;14(4):356-60.

4. Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood

experiences and smoking during adolescence and

adulthood. JAMA 1999 Nov 3;282(17):1652-8.

5. Dietz PM, Spitz AM, Anda RF, et al. Unintended pregnancy

among adult women exposed to abuse or household

dysfunction during their childhood. JAMA 1999 Oct

13;282(14):1359-64.

6. Hillis SD, Anda RF, Felitti VJ, et al. Adverse childhood

experiences and sexually transmitted diseases in men and

women: a retrospective study. Pediatrics 2000 Jul;106(1):E11.

7. Edwards VJ, Anda RF, Nordenberg DF, et al. Bias assessment

for child abuse survey: factors affecting probability of

response to a survey about childhood abuse. Child Abuse

Negl 2001 Feb;25(2):307-12.

8. Edwards VJ, Fivush R, Anda RF, et al. Autobiographical

memory disturbances in childhood abuse survivors. In:

Freyd JJ, DePrince AP, editors. Trauma and cognitive

science: a meeting of minds, science, and human experience. Binghamton (NY): Haworth Press; 2001. Published

simultaneously as a single-topic issue of J Aggression

Maltreatment Trauma Vol 4(2), No. 8.

9. Anda RF, Felitti VJ, Chapman DP, et al. Abused boys,

battered mothers, and male involvement in teen pregnancy.

Pediatrics 2001 Feb;107(2):E19.

10. Dube SR, Anda RF, Felitti VJ, et al. Adverse childhood

experiences and personal alcohol abuse as an adult. Addict

Behav. In press 2002.

11. Dube SR, Anda RF, Felitti VJ, et al. Exposure to abuse, neglect

and household dysfunction among adults who witnessed

intimate partner violence as children: implications for integrated

health and social services. Violence Vict. In press 2002.

12. Dube SR, Anda RF, Felitti VJ, et al. Childhood Abuse,

Household dysfunction, and the risk of attempted suicide

throughout the life span. Findings from the Adverse

Childhood Experiences Study. JAMA 2001;286:3089-3096.

... primary

issues are well

protected

by social

convention

and taboo ...