Research article
Adverse Childhood Experiences and the Risk of Premature Mortality

https://doi.org/10.1016/j.amepre.2009.06.021Get rights and content

Background

Strong, graded relationships between exposure to childhood traumatic stressors and numerous negative health behaviors and outcomes, healthcare utilization, and overall health status inspired the question of whether these adverse childhood experiences (ACEs) are associated with premature death during adulthood.

Purpose

This study aims to determine whether ACEs are associated with an increased risk of premature death during adulthood.

Methods

Baseline survey data on health behaviors, health status, and exposure to ACEs were collected from 17,337 adults aged >18 years during 1995–1997. The ACEs included abuse (emotional, physical, sexual); witnessing domestic violence; parental separation or divorce; and growing up in a household where members were mentally ill, substance abusers, or sent to prison. The ACE score (an integer count of the eight categories of ACEs) was used as a measure of cumulative exposure to traumatic stress during childhood. Deaths were identified during follow-up assessments (between baseline appointment date and December 31, 2006) using mortality records obtained from a search of the National Death Index. Expected years of life lost (YLL) and years of potential life lost (YPLL) were computed using standard methods. The relative risk of death from all causes at age ≤65 years and at age ≤75 years was estimated across the number of categories of ACEs using multivariable-adjusted Cox proportional hazards regression. Analysis was conducted during January–February 2009.

Results

Overall, 1539 people died during follow-up; the crude death rate was 91.0 per 1000; the age-adjusted rate was 54.7 per 1000. People with six or more ACEs died nearly 20 years earlier on average than those without ACEs (60.6 years, 95% CI=56.2, 65.1, vs 79.1 years, 95% CI=78.4, 79.9). Average YLL per death was nearly three times greater among people with six or more ACEs (25.2 years) than those without ACEs (9.2 years). Roughly one third (n=526) of those who died during follow-up were aged ≤75 years at the time of death, accounting for 4792 YPLL. After multivariable adjustment, adults with six or more ACEs were 1.7 (95% CI=1.06, 2.83) times more likely to die when aged ≤75 years and 2.4 (95% CI=1.30, 4.39) times more likely to die when aged ≤65 years.

Conclusions

ACEs are associated with an increased risk of premature death, although a graded increase in the risk of premature death was not observed across the number of categories of ACEs. The increase in risk was only partly explained by documented ACE-related health and social problems, suggesting other possible mechanisms by which ACEs may contribute to premature death.

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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