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Etiology & Impact

Long-Term Health

Robert Anda, MD, MS, and Vincent J. Felitti, MD

Adverse Childhood Experiences (ACEs) are strongly associated with many of the most serious diseases, disorders, and social problems,1 yet most health providers are ill equipped by their training to help prevent, identify, and to intervene early in the development of these harms. The Adverse Childhood Experiences (ACE) Study found a dose-response relationship between the number of categories of ACEs experienced and the number and severity of both illness risk factors and psychosocial/behavioral problems (i.e., smoking, obesity, physical inactivity, depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, and sexually transmitted diseases) and serious disease or other physical health problems (i.e., heart disease, cancer, stroke, chronic bronchitis, COPD, chronic pain, diabetes, hepatitis, and skeletal fractures) as well as health care utilization—especially rates of prescription pharmaceuticals used to treat these conditions.2,3,4,5,6 The cost to the health care system and society for these preventable sequelae is staggering.

The Adverse Childhood Experiences (ACE) Study is a landmark research study focusing on the role of childhood adversity, including violence and abuse and their relationship to long-term health.2 The ACE Study is an ongoing collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente that comprehensively describes the prevalence and the effects of 10 categories of adverse childhood experiences (ACEs), including: childhood abuse (emotional, physical, or sexual), childhood neglect (emotional or physical), and household dysfunction (witnessing domestic violence, substance abuse, mental illness, incarceration, or separation and divorce) on adult health and social well-being throughout the lifespan. Study participants include 17,000 middle-class adults from the Kaiser Health Plan in San Diego, CA.  More than 80 publications describing both retrospective and prospective analyses of this large study cohort repeatedly demonstrate that:

  • ACEs are common, but largely unrecognized.
  • ACEs are highly interrelated and often occur together.
  • The ACE Score is the number of categories of ACEs.
  • The ACE Score has strong and graded relationship to numerous health and social problems, as listed above.
  • The cumulative stressor effect of ACEs on human development throughout the lifespan shows that ACEs are major determinants of future health. Individuals with higher ACE scores have markedly increased risk of addiction, mental illness, social problems, health care utilization, chronic diseases, prescription medication use, and premature mortality.2,3,4

Depression and diabetes are two of the most serious and costly medical conditions throughout the world today. The World Health Organization has standardized ACE questions for use in multiple countries. As a result, public health surveillance efforts are beginning to document the national and global burden of ACEs.4 A study of ACEs in the Netherlands shows that ACEs are associated with a higher burden of disease than all non-ACE related common mental disorders combined.5 While this is true, the risks of the intergenerational transmission of ACEs is greatest for problems like household substance abuse and mental illness.2,4 A key to prevention of ACEs and all of their sequelae is the disruption of this intergenerational cycle with each successive generation.7 The pervasive influence of ACEs is now recognized as a serious international health and social problem, and a growing number of studies provide additional support to the validity of the concepts4 and importance of the ACE Study. 


1. Adverse Childhood Experiences: Looking at how ACEs affect our lives & society. CDC infographic. 

2. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174-86.

3. Brown DW, Anda RF Tiemeier, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009;37:389-396.

4. Anda RF, Butchart A, Felitti VJ, Brown DW.  Building a framework for global surveillance of the public health implications of adverse childhood experiences. Am J Prev Med 2010;39(1)93–98.

5. Cuijpers P, Smit F, Unger F, et al.  The disease burden of childhood adversities in adults: A population-based study. Child Abuse and Neglect 2011;35:937-945.

6. Anda RF, Brown DW, Felitti VJ, Dube SR, Giles WH. Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC Public Health. 2008;8:198.

7. Anda RF, Brown DW.  Root Causes and organic budgeting; funding health from conception to the grave.  Pediatric Health 2007;1(2):141-143.

© 2015 by Academy on Violence and Abuse