Adverse Childhood Experiences Reported by Adults --- Five States, 2009

Adverse childhood experiences (ACEs) include verbal, physical, or sexual abuse, as well as family dysfunction (e.g., an incarcerated, mentally ill, or substance-abusing family member; domestic violence; or absence of a parent because of divorce or separation). ACEs have been linked to a range of adverse health outcomes in adulthood, including substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality (1--3). Furthermore, data collected from a large sample of health maintenance organization members indicated that a history of ACEs is common among adults and ACEs are themselves interrelated (4). To examine whether a history of ACEs was common in a randomly selected population, CDC analyzed information from 26,229 adults in five states using the 2009 ACE module of the Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that, overall, 59.4% of respondents reported having at least one ACE, and 8.7% reported five or more ACEs. The high prevalence of ACEs underscores the need for 1) additional efforts at the state and local level to reduce and prevent child maltreatment and associated family dysfunction and 2) further development and dissemination of trauma-focused services to treat stress-related health outcomes associated with ACEs.

BRFSS is a surveillance system operated by state health departments in collaboration with CDC. Each month, trained interviewers using a standardized questionnaire collect data from a probability sample of the noninstitutionalized U.S. adult population residing in households with landline telephones. The 2009 ACE module consisted of 11 questions that yielded eight categories of ACEs (i.e., verbal abuse, physical abuse, sexual abuse, household mental illness, household substance abuse, domestic violence, parental separation/divorce, and incarcerated family members). These questions were adapted from large, validated survey instruments measuring the frequency of these ACEs.* The ACE module was implemented in five states (Arkansas, Louisiana, New Mexico, Tennessee, and Washington). Response rates for these states, calculated using the Council of American Survey Research Organizations (CASRO) guidelines, ranged from 48.2% to 59.8%.

Among the 29,212 adult survey participants, 1,757 (6.0%) who terminated the telephone call before the ACE module was administered and another 1,226 (4.2%) who refused to answer at least one of the 11 ACE questions were excluded. Thus, the sample included 26,229 (89.8%) of the interviewed BRFSS participants.

The prevalence of each ACE ranged from a high of 29.1% for household substance abuse to a low of having an incarcerated family member (7.2%) (Table 1). Approximately one quarter (25.9%) of respondents reported verbal abuse, 14.8% reported physical abuse, and 12.2% reported sexual abuse. For ACEs measuring family dysfunction, 26.6% reported separated or divorced parents; 19.4% reported that they had lived with someone who was depressed, mentally ill, or suicidal; and 16.3% reported witnessing domestic violence.

Men and women reported similar prevalences for each ACE, with the exception of sexual abuse (17.2% for women and 6.7% for men [p<0.05]), living with a mentally ill household member (22.0% for women and 16.7% for men [p<0.05]), and living with a substance-abusing family member (30.6% for women and 27.5% for men [p<0.05]). Younger respondents more often reported living with an incarcerated and/or mentally ill household member (p<0.05).

For each ACE, a sharp decrease was observed in prevalence reported by adults aged ≥55 years (p<0.05). For example, the prevalence of reported physical abuse was 16.9% among adults aged 18--24 years compared with 9.6% among those aged ≥55 years (p<0.05). Non-Hispanic black respondents reported the lowest prevalence of each ACE category among all racial/ethnic groups (p<0.05), with the exception of having had an incarcerated family member, parental separation or divorce, and witnessing domestic violence. Hispanics reported a higher prevalence than non-Hispanic whites of physical abuse (p<0.05), witnessing domestic violence (p<0.05), and having an incarcerated family member (p<0.05). Those respondents with less than a high school education compared with those with more than a high school education had a greater prevalence of physical abuse, an incarcerated family member, substance abuse, and separation/divorce (p<0.05 for all). Among the five states, little variation was observed (Table 1).

Approximately 41% of respondents reported having no ACEs (Table 2), 22% reported one ACE, and 8.7% reported five or more ACEs (Table 2). Men (6.9%) were less likely to report five or more ACEs compared with women (10.3%). Respondents aged ≥55 years reported the fewest ACEs, but the younger age groups did not differ from one another. Non-Hispanic blacks were less likely to report five or more ACEs (4.9%) compared with non-Hispanic whites (8.9%), Hispanics (9.1%), and other non-Hispanics (11.7%). However, non-Hispanic black respondents were not significantly more likely to report zero ACEs compared with other racial/ethnic groups. Respondents with the lowest educational attainment were significantly more likely to report five or more ACEs compared with those with higher education levels (14.9% versus 8.7% among high school graduates and 7.7% in those with more than a high school education [p<0.05]). Overall, little state-by-state variation was observed in the number of ACEs reported by each respondent.

Reported by

L Bynum, Arkansas Dept of Health. T Griffin, Louisiana Dept of Health. DL Ridings, Tennessee Dept of Health. KS Wynkoop, Washington Dept of Health. RF Anda, MD, Carter Consulting, Inc., Atlanta, Georgia. VJ Edwards, PhD, TW Strine, PhD, Y Liu, PhD, LR McKnight-Eily, PhD, JB Croft, PhD, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

This is the first published report to document the prevalence of ACEs in a population-based representative sample from multiple states stratified by demographic characteristics, including sex, age, education, and race/ethnicity. Approximately 59% of respondents reported one or more ACEs. These BRFSS estimates are similar to the findings in the Kaiser-CDC ACE study (2) and similar research, including a study in Texas (5,6).† Sexual abuse, family mental illness, and family substance abuse were reported more commonly by women than men. Although differences were observed in the prevalence of individual ACEs and number of ACEs, this study found that ACEs were common among all racial/ethnic groups. Participants aged ≥55 years reported significantly lower prevalences of all ACE categories than each of the younger age groups.

These findings reinforce the commonality of ACEs across racial/ethnic groups and states. Differences in reporting family mental illness and substance abuse by women might represent greater comfort with disclosing family problems. However, sexual abuse has been consistently reported by more women than men in many surveys and agencies' statistics, and this study confirms that finding. The markedly lower prevalences for all the ACE categories among those aged ≥55 years were similar to findings from the Kaiser-CDC ACE study (1), which suggested that a higher number of ACEs were associated with premature mortality (up to 20 years of life lost). Additionally, growing up with a family member in prison was inversely related to age; this might reflect the rising level of incarceration among the U.S. population.§

The findings in this report are subject to at least four limitations. First, the prevalences of ACEs might be underestimated because BRFSS excludes persons in institutions and hospitals, who might have experienced ACEs disproportionately. Second, BRFSS excludes persons who rely on cellular telephones as their only telephone service, thus underestimating the prevalence of ACES among persons aged 18--35 years or those more likely to use only a cellular phone. Third, this study covered only five states, and the results are not generalizeable to the entire U.S. adult population. Finally, BRFSS response rates were low, which increases the risk for response bias.

State-based surveillance of ACEs can provide guidance for the allocation of maltreatment prevention strategies and trauma-related intervention services.¶ In addition, more research is needed to disentangle the specific role each ACE plays in the development of health problems later in life. As it currently exists, the ACE total captures the cumulative risk associated with child maltreatment and family dysfunction, but could be further refined to address issues of unequal severity.

CDC is developing, evaluating, and promoting dissemination of programs for the primary prevention of child maltreatment.** Evidence-based programs exist that have demonstrated reductions in child maltreatment, such as home visits by nurses to mothers at high risk (7) and parenting programs that teach new skills and behaviors to parents (8). However, most child maltreatment goes undetected, as evidenced by the discrepancy between the incidence of confirmed cases of abuse reported by child protective services and retrospectively reported prevalences such as those described in this report. Therefore, secondary and tertiary efforts are important complementary approaches to primary prevention efforts to improve the health and well-being of affected adults and families. Psychological treatments that can mitigate the progression of ACE-related health problems, such as trauma-focused cognitive-behavioral therapy, are effective (9) and should be widely disseminated. Other promising public health programs, such as trauma survivors' networks (10), should be more systematically evaluated to add to the repertoire of available evidence-based interventions that can prevent and alleviate the stress-related health risk behaviors, conditions, and disability associated with ACEs.

Acknowledgments

The findings in this report are based, in part, on contributions by BRFSS state coordinators.

References

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;14:245--58.
2. Brown DW, Anda RF, Henning T, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009;37:389--96.
3. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 2006;256:174--86.
4. Dong M, Anda RF, Felitti VJ, et al. The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse Negl 2004;28;771-- 84.
5. Green JG, McLaughlin KA, Berglund PA, et al. Childhood adversities and adult psychiatric disorders in the National Comorbidity Survey Replication 1: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry 2010;67:113--23.
6. Lang J, Laffaye C, Satz LE, et al. Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care. Child Abuse Neg 2006;30:1281--91.
7. Eckenrode J, Campa M, Luckey DW, et al. Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Arch Pediatr Adolescent Med 2010;164:9--15.
8. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention of child maltreatment: the U.S. Triple P system population trial. Prev Sci 2009;10:1--12.
9. Wethington HR, Hahn RA, Fuqua-Whitley DS, et al. The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic review. Am J Prev Med 2008;35:287--313.
10. Bloom SL. The sanctuary model: developing generic inpatient programs for the treatment of psychological trauma. In: Williams, MB, Sommer, JF Jr (eds). Handbook of post-traumatic therapy, a practical guide to intervention, treatment, and research. Westport, Connecticut: Greenwood Publishing; 1994:474--91.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to [email protected].