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PEDIATRICS Vol. 111 No. 3 March 2003, pp. 564-572
Childhood Abuse, Neglect, and
Household Dysfunction and the Risk of
Illicit Drug Use: The Adverse Childhood
Experiences Study
, ,
, ,
and
Shanta R. Dube, MPH
*
Vincent J. Felitti, MD
Maxia Dong, MD, PhD
*
Daniel P. Chapman, PhD
*
Wayne H. Giles, MD
*
Robert F. Anda, MD
*
National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, Atlanta,
Georgia
Department of Preventive Medicine, Southern California
Permanente Medical Group (Kaiser Permanente), San Diego,
California
*
-->
Illicit drug use is identified in as a leading
health indicator because it is associated with multiple deleterious health
outcomes, such as sexually transmitted diseases, human immunodeficiency
virus, viral hepatitis, and numerous social problems among adolescents and
adults. Improved understanding of the influence of stressful or traumatic
childhood experiences on initiation and development of drug abuse is needed.
ABSTRACT
Objective. Healthy People 2010
We examined the relationship between illicit drug use and 10
categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A
retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a
survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related
issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age
Methods.
This Article
Abstract
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Related AAP Red Book topics:
Human Immunodeficiency Virus...
TOP
ABSTRACT
INTRODUCTION
METHODS
Definition of Illicit Drug...
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
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categories: 14 years, 15 to 18 years, or as an adult ( 19 years); lifetime use for each of 4 birth cohorts
dating back to 1900; drug use problems; drug addiction; and parenteral drug use.
Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong
graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug
addiction, and parenteral drug use. Compared with people with 0 ACEs, people with 5 ACEs were 7- to
10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use.
The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%,
64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong
graded relationship to lifetime drug use.
Results.
The ACE score had a strong graded relationship to the risk of drug initiation from early
adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The
persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth
cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular
changes such as increased availability of drugs, social attitudes toward drugs, and
recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to
account for one half to two third of serious problems with drug use, progress in meeting the national goals
for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing
childhood experiences by pediatric practice.
Conclusions.
childhood abuse • domestic violence • drug use • substance abuse • parenteral drug useKey Words:
ACE, adverse childhood experience • CTS, Conflict Tactics Scale • CTQ, Childhood
Trauma Questionnaire • SD, standard deviation • OR, odds ratio • CI, confidence interval • ARF,
attributable risk fraction
Abbreviations:
Psychoactive substances have been used and abused for thousands of years.
It is now known that illicit drug use increases the risk of behaviors that lead to
sexually transmitted diseases, intentional and unintentional injuries, cardiac
problems, interpersonal violence, disability, and crime. Moreover,
parenteral drug use is an important avenue for transmission of hepatitis B and
C and the human immunodeficiency virus. Because of these multiple
serious consequences, substance abuse is 1 of the nation’s 10 leading health
indicators outlined in , which includes the goal of
reducing the proportion of people who use illicit drugs.
INTRODUCTION
1
–2 13
–13 16
Healthy People 2010
13
Drug use is usually initiated during adolescence ; thus, many national studies have focused on members
of this age group, who often find illicit drugs readily available. In fact, a recent national study of 12- to
17-year-olds found that 55% find marijuana easy to obtain. Furthermore, as part of a normal
developmental pathway, adolescents often experiment and behave impulsively and seek independence
17
18
18
19
20
TOP
ABSTRACT
INTRODUCTION
METHODS
Definition of Illicit Drug...
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
04-09-05 19:33Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study -- Dube et al. 111 (3): 564 -…
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and autonomy. This constellation of inherent behaviors combined with easy access to drugs may
contribute to the increased risk of using illicit drugs during adolescence.
–19 21
Despite this body of knowledge about the use of illicit drugs, additional research is needed to understand
and assess the influence of experiential factors that may contribute to the initiation and subsequent problems
with illicit drug use at any age. Previous studies suggested that early childhood trauma can lead to an array
of negative health outcomes and behaviors, including substance abuse, among both adolescents and
adults. For example, childhood physical and sexual abuse has been shown to be associated with
illegal drug use. Although these studies provide evidence that most substance abusers come from
abusive homes, many of these studies have taken a "categorical" approach to examine the relationship
between 1 or 2 forms of these childhood exposures and subsequent drug abuse; few studies have
examined illicit drug use and abuse in relation to multiple disturbing or stressful childhood exposures.
Previous reports from the Adverse Childhood Experiences Study have established that forms of childhood
abuse, neglect, and household dysfunction tend to co-occur, and the effects of these developmentally
disruptive childhood experiences have repeatedly been shown to be strong and cumulative.
–22 25
–26 28
,29 30
–29 35
This study examined the association between 10 categories of adverse childhood experiences (ACEs):
abuse (physical, emotional, or sexual); neglect (physical or emotional); and growing up with household
substance abuse, criminality of household members, mental illness among household members, and
parental discord and illicit drug use. We then use a cumulative stressor model to examine the relationship
between the number of ACEs (ACE score) and the initiation of illicit drug use by three age categories. We
assess the relationships between the ACE score and lifetime use of illicit drugs for four successive birth
cohorts dating back to 1900, problems with illicit drug use, addiction to illicit drugs, and parenteral drug
use. Finally, we estimate the proportion of each of these three serious problems of drug abuse that
are attributable to adverse childhood experiences.
The Adverse Childhood Experiences (ACE) Study is
a collaboration between the Kaiser Health Plan’s Health Appraisal Center in
San Diego, CA, and the Centers for Disease Control and Prevention. The
overall objective is to assess the impact of numerous, interrelated, ACEs on a
wide variety of health behaviors and outcomes. The ACE Study was
approved by the Institutional Review Boards of the Southern California
Permanente Medical Group (Kaiser Permanente), Emory University, and
Office of Human Research Protection, Department of Health and Human
Services (formerly Office of Protection from Research Risks, National Institutes of Health).
Recent publications from the ACE Study have shown a strong, graded relationship between the number of
ACEs and the leading causes of death in the United States and priority health and social problems such
as smoking, unintended pregnancies, sexually transmitted diseases, male involvement in teen
pregnancy, alcohol problems, and attempted suicides.
METHODS
29
29
30 31 32
33 34 35
The study population included adult members of the Kaiser Health Plan who received a standardized
Study Population
TOP
ABSTRACT
INTRODUCTION
METHODS
Definition of Illicit Drug...
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
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medical and biopsychosocial examination at Kaiser’s Health Appraisal Center in San Diego, CA. In any
4-year period, 81% of adult members received the examination, and >50 000 members receive it
annually. The primary purpose of the evaluation is to perform a complete health assessment rather than
provide symptom- or illness-based care. The ACE Study consisted of 2 survey waves (wave I and wave
II). Wave I was conducted among 13 494 consecutive members who attended the Health Appraisal Center
between August 1995 and March 1996, and the response rate was 70% ( = 9508). Wave II was conducted
between June and October 1997 among 13 330 members, and the response rate was 65% ( = 8667). The
overall response rate was 68% (18 175 of 26 824).
n
n
The ACE questionnaire was mailed to each member 2 weeks after his or her evaluation at the Health
Appraisal Center and contained detailed information about ACEs, including abuse (emotional, physical, or
sexual) or household dysfunction (parental separation or divorce, domestic violence, substance abuse,
crime, or mental illness) as well as additional information about health-related behaviors from adolescence
to adulthood. The wave II questionnaire added questions to obtain more thorough information about
health topics shown to be important during the analysis of wave I data. For these analyses, we used
data from wave II only, because it included detailed questions about illicit drug use that were not included
in the wave I survey.
,29 31
As part of the wave I study design, the standardized health examination data from the clinic visit were
abstracted for both respondents and nonrespondents to the ACE Study questionnaire; this enabled a
detailed assessment of the study population in terms of possible bias in demographic characteristics and
health-related issues. Although nonrespondents tended to be younger, less educated, or from racial/ethnic
minority groups, the probabilities of both psychosocial and health problems were remarkably
similar between respondents and nonrespondents after controlling for demographic differences. In addition,
assessment of the relationships between childhood sexual abuse and numerous health behaviors, diseases,
and psychosocial problems that were abstracted from data from the Health Appraisal Center showed that
they were virtually identical for respondents and nonrespondents. Thus, there was no evidence that
respondents were biased toward attributing their health problems to childhood experiences such as
sexual abuse.
Assessment of Representativeness, and Response or Reporting Bias
36
36
36
We excluded 3 respondents with missing information about race and 35 with missing information about
educational attainment. We also excluded 16 people who reported using illicit drugs but did not report age
at initiation. Thus, the final study cohort included 99% of the respondents from wave II only (8613 of
8667).
Exclusions From the Study Cohort
All questions about ACEs pertained to the respondents’ first 18 years of life. For questions adapted from
the Conflict Tactics Scale (CTS), response categories were "never," "once or twice," "sometimes,"
"often," or "very often." Questions used to define emotional and physical neglect were adapted from the
Childhood Trauma Questionnaire (CTQ). Response categories were "never true," "rarely true,"
"sometimes true," "often true," and "very often true" and were scored on a Likert scale (1–5), respectively.
Some items from the CTQ were reverse-scored on the basis of the context of the question.
Definition of ACEs
37
38
38
Abuse Variables
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Emotional abuse and physical abuse were defined by 2 questions from the CTS. For emotional abuse, the
questions were as follows: 1) "How often did a parent, stepparent, or adult living in your home swear at
you, insult you, or put you down?" 2) "How often did a parent, stepparent, or adult living in your home act
in a way that made you afraid that you might be physically hurt?" Responses of "often’ or "very often" to
either item defined emotional abuse during childhood. For physical abuse, the questions were as follows:
"Sometimes parents or other adults hurt children. While you were growing up, that is, in your first 18 years
of life, how often did a parent, stepparent, or adult living in your home 1) push, grab, slap, or throw
something at you? 2) hit you so hard that you had marks or were injured?" Responses of "sometimes,"
"often," or "very often" to either item defined physical abuse during childhood.
Contact sexual abuse was defined by 4 questions from Wyatt : "Some people, while they are growing up
in their first 18 years of life, had a sexual experience with an adult or someone at least 5 years older than
themselves. These experiences may have involved a relative, family friend, or stranger. During the first 18
years of life, did an adult, relative, family friend, or stranger ever 1) touch or fondle your body in a sexual
way, 2) have you touch their body in a sexual way, 3) attempt to have any type of sexual intercourse with
you (oral, anal, or vaginal), or 4) actually have any type of sexual intercourse with you (oral, anal, or
vaginal)?" A "yes" response to any 1 of the 4 questions classified a respondent as having experienced this
kind of abuse.
39
For both emotional and physical neglect, sets of 5 CTQ items were used. For emotional neglect, these were
1) "There was someone in my family who helped me feel important or special." 2) "I felt loved." 3)
"People in my family looked out for each other." 4) "People in my family felt close to each other." 5) "My
family was a source of strength and support." All items were reverse-scored, then summed. Scores of 15
(moderate to extreme on the CTQ clinical scale) defined the respondents as having experienced
emotional neglect.
Neglect Variables
The 5 items for physical neglect were 1) "I didn’t have enough to eat." 2) "I knew there was someone there
to take care of me and protect me." 3) "My parents were too drunk or too high to take care of me." 4) "I
had to wear dirty clothes." 5) "There was someone to take me to the doctor if I needed it." Items 2 and 5
were reverse-scored, and all 5 scores were summed. Scores of 10 (moderate to extreme on the CTQ
clinical scale) were defined as physical neglect.
Having had a battered mother was defined by the following item from the CTS: "Sometimes physical
blows occur between parents." How often did your father (or stepfather) or mother’s boyfriend do any of
these things to your mother (or stepmother)? 1) Push, grab, slap, or throw something at her, 2) kick, bite, hit
her with a fist, or hit her with something hard, 3) repeatedly hit her over at least a few minutes, or 4)
threaten her with a knife or gun, or use a knife or gun to hurt her." A response of "sometimes," "often," or
"very often" to the first or second question or any response except for "never" to the third or the fourth
question was considered evidence of having a battered mother.
Household Dysfunction Variables
Parental separation or divorce was defined by a "yes" response to the question, "Were your parents ever
separated or divorced?" Mental illness in household was defined by an affirmative response to 1 or both of
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