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What is the prevalence of adverse childhood experiences across 23 states stratified by demographic characteristics?
In this cross-sectional survey of 214 157 respondents, participants who identified as black, Hispanic, or multiracial, those with less than a high school education, those with annual income less than $15 000, those who were unemployed or unable to work, and those identifying as gay/lesbian or bisexual reported significantly higher exposure to adverse childhood experiences than comparison groups.
These findings highlight the importance of understanding why some individuals are at higher risk of experiencing adverse childhood experiences than others, including how this increased risk may exacerbate health inequities across the lifespan and future generations.
Early adversity is associated with leading causes of adult morbidity and mortality and effects on life opportunities.
To provide an updated prevalence estimate of adverse childhood experiences (ACEs) in the United States using a large, diverse, and representative sample of adults in 23 states.
Design, Setting, and Participants
Data were collected through the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey on health-related behaviors, health conditions, and use of preventive services, from January 1, 2011, through December 31, 2014. Twenty-three states included the ACE assessment in their BRFSS. Respondents included 248 934 noninstitutionalized adults older than 18 years. Data were analyzed from March 15 to April 25, 2017.
Main Outcomes and Measures
The ACE module consists of 11 questions collapsed into the following 8 categories: physical abuse, emotional abuse, sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation or divorce. Lifetime ACE prevalence estimates within each subdomain were calculated (range, 1.00-8.00, with higher scores indicating greater exposure) and stratified by sex, age group, race/ethnicity, annual household income, educational attainment, employment status, sexual orientation, and geographic region.
Of the 214 157 respondents included in the sample (51.51% female), 61.55% had at least 1 and 24.64% reported 3 or more ACEs. Significantly higher ACE exposures were reported by participants who identified as black (mean score, 1.69; 95% CI, 1.62-1.76), Hispanic (mean score, 1.80; 95% CI, 1.70-1.91), or multiracial (mean score, 2.52; 95% CI, 2.36-2.67), those with less than a high school education (mean score, 1.97; 95% CI, 1.88-2.05), those with income of less than $15 000 per year (mean score, 2.16; 95% CI, 2.09-2.23), those who were unemployed (mean score, 2.30; 95% CI, 2.21-2.38) or unable to work (mean score, 2.33; 95% CI, 2.25-2.42), and those identifying as gay/lesbian (mean score 2.19; 95% CI, 1.95-2.43) or bisexual (mean score, 3.14; 95% CI, 2.82-3.46) compared with those identifying as white, those completing high school or more education, those in all other income brackets, those who were employed, and those identifying as straight, respectively. Emotional abuse was the most prevalent ACE (34.42%; 95% CI, 33.81%-35.03%), followed by parental separation or divorce (27.63%; 95% CI, 27.02%-28.24%) and household substance abuse (27.56%; 95% CI, 27.00%-28.14%).
Conclusions and Relevance
This report demonstrates the burden of ACEs among the US adult population using the largest and most diverse sample to date. These findings highlight that childhood adversity is common across sociodemographic characteristics, but some individuals are at higher risk of experiencing ACEs than others. Although identifying and treating ACE exposure is important, prioritizing primary prevention of ACEs is critical to improve health and life outcomes throughout the lifespan and across generations.
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Accepted for Publication: June 12, 2018.
Correction: This article was corrected on November 5, 2018, to fix transposed row labels and data under the “Sexual orientation” heading in Table 2.
Corresponding Author: Melissa T. Merrick, PhD, Division of Violence Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop F63, Atlanta, GA 30341 (firstname.lastname@example.org).
Published Online: September 17, 2018. doi:10.1001/jamapediatrics.2018.2537
Author Contributions: Drs Merrick and Ford had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Merrick, Ford, Ports.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Merrick, Ford.
Administrative, technical, or material support: All authors.
Supervision: Merrick, Ports.
Conflict of Interest Disclosures: None reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC). The Behavioral Risk Factor Surveillance System (BRFSS) data used in these analyses were supported by the CDC and obtained from the Alaska Department of Health and Social Services Division of Public Health; Arizona Department of Health Services; California Department of Public Health Behavioral Risk Factor Survey Workgroup; Colorado Department of Health and Environment; State of Connecticut Department of Public Health; Florida Department of Health; Iowa Department of Public Health; Kansas Department of Health and Environment; Maine Centers for Disease Control and Prevention, Data, Research, and Vital Statistics; Michigan Department of Community Health; Minnesota Department of Health; Montana Department of Public Health and Human Services; Nebraska Department of Health and Human Services; Nevada Department of Health and Human Services Division of Public and Behavioral Health; North Carolina Division of Public Health State Center for Health Statistics; Oklahoma State Department of Health; Oregon Health Authority Public Health Division; Pennsylvania Department of Health; South Carolina Department of Health and Environmental Control; Tennessee Department of Health; Utah Department of Health; Vermont Department of Health; Washington State Department of Health; and Wisconsin Department of Health Services. Use of these data does not imply that the states or the CDC agrees or disagrees with the analyses, interpretations, or conclusions in this report.
Additional Contributions: We thank all the participating states and departments of health.
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