Adverse childhood experiences and the risk of premature mortality.
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.


OBJECTIVE
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 < or =65 years and at age < or =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 < or =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 < or =75 years and 2.4 (95% CI=1.30, 4.39) times more likely to die when aged < or =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.
Brown
David W
DW
Centers for Disease Control and Prevention, Atlanta, GA 30341, USA. dbrown6@cdc.gov
Anda
Robert F
RF
Tiemeier
Henning
H
Felitti
Vincent J
VJ
Edwards
Valerie J
VJ
Croft
Janet B
JB
Giles
Wayne H
WH
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002649:Child Abuse / Q000706:statistics & numerical data*; D016241:Child of Impaired Parents / Q000706:statistics & numerical data*; D015331:Cohort Studies; D004243:Divorce / Q000706:statistics & numerical data; D017579:Domestic Violence / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D011329:Prisoners / Q000706:statistics & numerical data; D011446:Prospective Studies; D012307:Risk Factors; D055815:Young Adult