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Cited by 18,943Child Abuse and TraumaIntimate Partner and Family ViolenceChild Welfare and Adoption

Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults

Open access
Felitti, Vincent J, Anda, Robert F, Nordenberg, Dale, Williamson, David F, Spitz, Alison M, Edwards, Valerie, Koss, Mary P, Marks, James S·1998·American Journal of Preventive Medicine
DOI 10.1016/s0749-3797(98)00017-8
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Abstract

Background The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. Methods A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. Results More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of…

Integrity signals

Registry

Crossref · 10.1016/s0749-3797(98)00017-8

Cites

94 of 94 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

1 of 49 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Longitudinal follow-up of adults whose childhood abuse was well documented has shown that their retrospective reports of childhood abuse are likely to under-estimate actual occurrence.

    “Longitudinal follow-up of adults whose childhood abuse was well documented has shown that their retrospective reports of childhood abuse are likely to under-estimate actual occurrence.47,48”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [47] Femina, 1990, Child abuse, Child Abuse Negl source

      The Results report that eight adults with well-documented abuse in their adolescent records denied it at follow-up, and the Discussion says retrospective inaccuracies in this sample were in the direction of under-reporting. The paper limits that finding to a small sample of former delinquents and says its generalizability is uncertain; the claim does not retain that population qualifier. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [48] Williams, 1995, Recovered memories of abuse in women with documented child sexual victimization histories, J Traumatic Stress source
  • Findingown data

    One-fourth of ACE Study respondents reported at least two categories of adverse childhood exposure.

    “More than half of respondents reported at least one, and one-fourth reported Ն2 categories of childhood exposures.”
    Quote in the paperNot a substantial claim
  • Findingown data

    There is no statistically significant dose-response relationship between the number of childhood exposures and a history of stroke or diabetes.

    “There was no statistically significant dose-response relationship for a history of stroke or diabetes.”
    Quote in the paperNot a substantial claim
  • Findingown data

    There is a strong dose-response relationship between the number of childhood exposures and each of the 10 risk factors for leading causes of death studied (P < .001).

    “we found a strong, dose-response relationship between the number of childhood exposures and each of the 10 risk factors for the leading causes of death that we studied (P Ͻ .001).”
    Quote in the paperSubstantial claim
  • Findingown data

    Persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

    “The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.”
    Quote in the paperSubstantial claim
  • May combine two claims. 16
  • Classified as probably not a substantial claim. 22
  • The quote only partly states this claim. 2

  • May combine two claims.

    Findingown data

    Persons with four or more categories of childhood exposure, compared to those with none, had a 2- to 4-fold increase in smoking, poor self-rated health, 50 or more sexual intercourse partners, and sexually transmitted disease.

    “a 2-to 4-fold increase in smoking, poor self-rated health, Ն50 sexual intercourse partners, and sexually transmitted disease;”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among persons with no childhood exposures, 56% had none of the 10 risk factors, whereas only 14% of persons with 4 or more categories of childhood exposure had no risk factors.

    “For example, among persons with no childhood exposures, 56% had none of the 10 risk factors whereas only 14% of persons with Ն4 categories of childhood exposure had no risk factors.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The most prevalent of the seven categories of childhood exposure was substance abuse in the household (25.6%); the least prevalent was criminal behavior in the household (3.4%).

    “The most prevalent of the 7 categories of childhood exposure was substance abuse in the household (25.6%); the least prevalent exposure category was evidence of criminal behavior in the household (3.4%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only 1% of persons with no childhood exposures had four or more risk factors, whereas 7% of persons with 4 or more childhood exposures had four or more risk factors.

    “By contrast, only 1% of persons with no childhood exposures had four or more risk factors, whereas 7% of persons with Ն4 childhood exposures had four or more risk factors (Table 6).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the ACE Study sample, the prevalence of mental illness was 18.8%.

    “| Mental illness | | 18.8 |”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    Among participants aged 65 years or older, 60.0% reported no categories of adverse childhood exposure, compared with 35.4% among those aged 19-34.

    “| Ն65 | 2,610 | 60.0 | 24.5 | 8.9 | 4.2 | 2.4 |”
    • Also stated in: § Discussion · plain
      “| 19-34 | 807 | 35.4 | 25.4 | 17.2 | 11.0 | 10.9 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the ACE Study sample, the prevalence of psychological abuse was 11.1%.

    “| Psychological | | 11.1 |”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the ACE Study sample, the prevalence of mother treated violently was 12.5%.

    “| Mother treated violently | | 12.5 |”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In the ACE Study, among persons with 0 categories of adverse childhood exposure, 56% had 0 risk factors for the leading causes of death, compared with 14% among those with 4 or more categories.

    “| 0 | 3,861 | 56 | 29 | 10 | 4 | 1 |”
    • Also stated in: § Discussion · plain
      “| Ն4 | 545 | 14 | 26 | 28 | 17 | 7 |”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The number of categories of adverse childhood exposure is a valid cumulative measure of adversity.

  • May combine two claims.

    Findingown data

    The odds ratios for skeletal fractures, hepatitis or jaundice, and poor self-rated health were 1.6, 2.3, and 2.2, respectively.

    “Similarly, the odds ratios for skeletal fractures, hepatitis or jaundice, and poor self-rated health were 1.6, 2.3, and 2.2, respectively (Table 8).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In the ACE Study sample, the prevalence of substance abuse was 25.6%.

    “| Substance abuse | | 25.6 |”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The probability that persons exposed to any single category of exposure were also exposed to another category was significant for all comparisons (P < .001); for persons reporting any single category, the probability of any additional category ranged from 65% to 93% (median 80%).

    “The relationship between single categories of exposure was significant for all comparisons (P Ͻ .001;chi-square).For persons reporting any single category of exposure, the probability of exposure to any additional category ranged from 65%-93% (median: 80%); similarly, the probability of Ն2 additional exposures ranged from 40%-74% (median: 54.5%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Adverse childhood experiences are common and have strong long-term associations with adult health risk behaviors, health status, and diseases.

    “Because adverse childhood experiences are common and they have strong long-term associations with adult health risk behaviors, health status, and diseases, increased attention to primary, secondary, and tertiary prevention strategies is needed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Respondents and nonrespondents were similar in their percentages of women and in their mean years of education.

    “Respondent (n ϭ 9,508) and nonrespondent (n ϭ 3,986) groups were similar in their percentages of women (53.7% and 51.0%, respectively) and in their mean years of education (14.0 years and 13.6 years, respectively).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The response rate for the ACE Study survey was 70.5% (9,508/13,494).

    “After second mailings of the questionnaire to persons who did not respond to the first mailing, the response rate for the survey was 70.5% (9,508/13,494).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Respondents were slightly more likely than nonrespondents to answer affirmatively to a single question about childhood sexual abuse (6.1% vs 5.4%).

    “Respondents were slightly more likely to answer affirmatively than nonrespondents (6.1% vs. 5.4%, respectively).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Without measuring household factors as well, long-term influence might be wrongly attributed solely to single types of abuse and the cumulative influence of multiple categories of adverse childhood experiences would not be assessed.

    “Without measuring these household factors as well, long-term influence might be wrongly attributed solely to single types of abuse and the cumulative influence of multiple categories of adverse childhood experiences would not be assessed.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Conditions such as drug abuse, spousal violence, and criminal activity in the household may co-occur with specific forms of abuse that involve children.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The ACE Study questionnaire used questions from published surveys to construct measures of childhood exposures and health-related behaviors.

    “We used questions from published surveys to construct the ACE Study questionnaire.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [39] Straus, 1990 source
    • cites [40] Wyatt, 1985, The sexual abuse of Afro-American and White-American women in childhood, Child Abuse Negl source
    • cites [41] National Center for Health Statistics. Exposure to alcoholism in the family: United States, 1988. Advance Data, No. 205. U.S. Department of Health and Human Services, Washington, DC; September 30, 1991.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Respondents were older and more likely to be white than nonrespondents, although the magnitude of the differences was small.

    “Respondents were older than nonrespondents (means 56.1 years and 49.3 years) and more likely to be white (83.9% vs. 75.3%)although the actual magnitude of the differences was small.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Studies of the long-term effects of childhood abuse have usually examined single types of abuse, particularly sexual abuse, and few have assessed the impact of more than one type of abuse.

    “Studies of the long-term effects of childhood abuse have usually examined single types of abuse, particularly sexual abuse, and few have assessed the impact of more than one type of abuse.5,24 -28”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [5] McCauley, 1997, Clinical characteristics of women with a history of childhood abuse, JAMA source
    • cites [24] Briere, 1988, Multivariate correlates of childhood psychological and physical maltreatment among university women, Child Abuse Negl source
    • cites [25] Briere, 1990, Differential adult symptomatology associated with three types of child abuse histories, Child Abuse Negl source
    • cites [26] Claussen, 1991, Physical and psychological maltreatment, Child Abuse Negl source
    • cites [27] Moeller, 1993, The combined effects of physical, sexual, and emotional abuse during childhood, Child Abuse Negl source
    • cites [28] Bryant, 1995, Suicidality in college women who were sexually and physically punished by parents, Violence Vict source

  • May combine two claims.

    Study design and conductown data

    Respondents and nonrespondents did not differ with regard to self-rated health, smoking, other substance abuse, common medical conditions, marital status, or current family, marital, or job-related problems.

    “Respondents and nonrespondents did not differ with regard to their self-rated health, smoking, other substance abuse, or the presence of common medical conditions such as a history of heart attack or stroke, chronic obstructive lung disease, hypertension, or diabetes, or with regard to marital status or current family, marital, or job-related problems (data not shown).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The American Medical Association recommends screening of women for exposure to violence at every entrance to the health system.

    “For example, the American Medical Association recommends screening of women for exposure to violence at every entrance to the health system; 66 however, such screening appears to be rare.67”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [66] 1992, American Medical Association Diagnostic and Treatment Guidelines on Domestic Violence, Arch Fam Med

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    There may be mediators of the relationship between childhood experiences and adult health status other than the risk factors examined.

    “In addition, there may be mediators of the relationship between childhood experiences and adult health status other than the risk factors we examined.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    High levels of exposure to adverse childhood experiences would expectedly produce anxiety, anger, and depression in children.

    “High levels of exposure to adverse childhood experiences would expectedly produce anxiety, anger, and depression in children.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Adolescent health care is often inadequate in terms of psychosocial assessment and anticipatory guidance.

    “Although articles in the general medical literature are alerting the medical community to the fact that childhood abuse is common, 59 adolescent health care is often inadequate in terms of psychosocial assessment and anticipatory guidance.60”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Rixey, 1994, Family violence and the adolescent, Maryland Med J

  • May combine two claims.

    Premisecitation

    Nicotine is recognized as having beneficial psychoactive effects in terms of regulating affect, and persons who are depressed are more likely to smoke.

    “For example, nicotine is recognized as having beneficial psychoactive effects in terms of regulating affect 49 and persons who are depressed are more likely to smoke.50,51”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [49] Carmody, 1989, Affect regulation, nicotine addiction, and smoking cessation, J Psychoactive Drugs source
    • cites [50] Anda, 1990, Depression and the dynamics of smoking. A national perspective, JAMA source
    • cites [51] Glassman, 1990, Smoking, smoking cessation, and major depression, JAMA source

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    To the degree that behaviors such as smoking, alcohol, or drug use are found to be effective as coping devices, they would tend to be used chronically.

    “To the degree that behaviors such as smoking, alcohol, or drug use are found to be effective as coping devices, they would tend to be used chronically.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Many physicians may fear that discussions of sexual violence and other sensitive issues are too personal even for the doctor-patient relationship.

    “Many physicians may fear that discussions of sexual violence and other sensitive issues are too personal even for the doctor-patient relationship.65”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [65] Sugg, 1992, Primary care physicians’ response to domestic violence. Opening Pandora’s box, JAMA source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Self-rated health is strongly predictive of mortality.

    “because it is strongly predictive of mortality.45”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [45] Idler, 1990, Self-rated health and mortality in the NHANES I Epidemiologic Follow-up Study, Am J Pub Health source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    Some persons with health risk behaviors or diseases may have been either more, or less, likely to report adverse childhood experiences.

    “Second, some persons with health risk behaviors or diseases may have been either more, or less, likely to report adverse childhood experiences.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Childhood exposures include emotionally sensitive topics such as family alcoholism and sexual abuse.

    “Moreover, these childhood exposures include emotionally sensitive topics such as family alcoholism 29,30 and sexual abuse.64”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [29] Zeitlen, 1994, Children with alcohol misusing parents, Br Med Bull source
    • cites [30] Dore, 1995, Identifying substance abuse in maltreating families, Child Abuse Negl source
    • cites [64] Tabachnick, 1997, Perceptions of child sexual abuse as a public health problem. Vermont, September 1995, Morb Mortal Wkly Rep

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    Disease conditions could be either over- or under-reported by patients when they complete the medical questionnaire.

    “Furthermore, disease conditions could be either over-or under-reported by patients when they complete the medical questionnaire.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The relationship between childhood experiences and adult health status is likely to be overlooked in medical practice because the time delay between exposure during childhood and recognition of health problems in adult medical practice is lengthy.

    “The relationship between childhood experiences and adult health status is likely to be overlooked in medical practice because the time delay between exposure during childhood and recognition of health problems in adult medical practice is lengthy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The data about adverse childhood experiences are based on self-report and retrospective, and can only demonstrate associations between childhood exposures and health risk behaviors, health status, and diseases in adulthood.

    “The data about adverse childhood experiences are based on self-report, retrospective, and can only demonstrate associations between childhood exposures and health risk behaviors, health status, and diseases in adulthood.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Smoking, which is medically and socially viewed as a problem, may from the perspective of the user represent an effective immediate solution that leads to chronic use.

    “Thus, smoking, which is medically and socially viewed as a “problem” may, from the perspective of the user, represent an effective immediate solution that leads to chronic use.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Childhood abuse is common.

    “Although articles in the general medical literature are alerting the medical community to the fact that childhood abuse is common, 59 adolescent health care is often inadequate in terms of psychosocial assessment and anticipatory guidance.60”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [59] MacMillan, 1997, Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement, JAMA source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Logistic regression was used to adjust for potential confounding effects of age, sex, race, and educational attainment on the relationship between the number of childhood exposures and health problems.

    “Logistic regression analysis was employed to adjust for the potential confounding effects of age, sex, race, and educational attainment on the relationship between the number of childhood exposures and health problems.”
    Quote in the paperSubstantial claim
37 of 37

  • The paper relies on this without support.

    Conditions such as drug abuse, spousal violence, and criminal activity in the household may co-occur with specific forms of abuse that involve children.

    “Conditions such as drug abuse, spousal violence, and criminal activity in the household may co-occur with specific forms of abuse that involve children.”

  • The paper relies on this without support.

    The number of categories of adverse childhood exposure is a valid cumulative measure of adversity.

    “Number of categories of adverse childhood exposure and the adjusted odds of risk factors including current smoking, severe obesity, physical inactivity, depressed mood, and suicide attempt”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The study used the 10-item ACE Study questionnaire to measure childhood trauma.

    “Adverse childhood experiences (ACEs) were documented at baseline using the 10-item ACE Study questionnaire to measure childhood trauma, and were grouped as either “0–3” or “4+” due to the high rate of chronic health problems among individuals with scores of 4 or more 37.”

    From Effects of a trauma-informed mindful recovery program on comorbid pain, anxiety, and substance use during primary care buprenorphine treatment: A proof-of-concept study (2023) · cites this paper as [37]

    The Survey Methods and Questionnaire Design sections confirm that the paper used an ACE Study questionnaire about childhood abuse and household dysfunction. But the Adverse Childhood Exposures section says it included 17 questions across seven categories, not 10 items. Page numbers are unavailable in our copy. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • Both exposure to IPV and parental separation or divorce are two adverse childhood experiences (ACEs) that are linked in a dose-response relationship to adverse health consequences through the lifespan.

    “Both exposure to IPV and parental separation or divorce are two adverse childhood experiences (ACEs) that are linked in a dose–response relationship to adverse health consequences through the lifespan (Felitti et al., 1998).”

    From Post‐separation abuse: A concept analysis (2023) · cites this paper as Felitti et al., 1998

    The 'Defining Childhood Exposures' section includes violent treatment of a mother or stepmother as an ACE, but its seven categories do not include parental separation or divorce. The Discussion reports a dose-response relationship between the total number of exposure categories and adult health risks, not a separate dose-response relationship for each named experience or outcomes measured throughout the lifespan. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • There is a strong, graded link between exposure to childhood adversity and risk of negative health, social, and emotional outcomes, including several major categories of chronic disease, lung cancer, various autoimmune diseases, depression and other mental illnesses, and high-risk behaviors.

    “There is a strong, graded link between exposure to childhood adversity and risk of negative health, social, and emotional outcomes, including several major categories of chronic disease, lung cancer, various autoimmune diseases, depression and other mental illnesses, and high-risk behaviors (e.g., Felitti et al., 1998).”

    From Malleability, plasticity, and individuality: How children learn and develop in context<sup>1</sup> (2019) · cites this paper as Felitti et al., 1998

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • On average, the life span of individuals with six or more ACEs is 20 years shorter than that of those with zero ACEs.

    “on average, the life span of individuals with six or more ACEs is 20 years shorter than that of those with zero ACEs (Felitti et al., 1998).”

    From Malleability, plasticity, and individuality: How children learn and develop in context<sup>1</sup> (2019) · cites this paper as Felitti et al., 1998

    The Discussion (page not supplied) raises premature mortality among people with multiple adverse childhood exposures as a possibility, not a measured finding. The Abstract compares health risks for people with four or more exposure categories against those with none; it does not report a 20-year lifespan difference for people with six or more ACEs. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Adults with ELS/CT experience could be at increased risk of disease with potentially immune origin.

    “while adults with ELS/CT experience could be at increased risk of disease with potentially immune origin (36, 53).”

    From Developmental Trajectories of Early Life Stress and Trauma: A Narrative Review on Neurobiological Aspects Beyond Stress System Dysregulation (2019) · cites this paper as [53]

    The Relationship between Childhood Exposures and Disease Conditions section reports higher odds of several adult diseases among people with four or more categories of adverse childhood exposure. The Discussion also describes graded associations with heart, lung, liver and other diseases. Our copy does not characterize those diseases as having a potentially immune origin, so that qualification is not supported by this source. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract claims significant trends for diseases later reported as nonsignificant

    Major

    The abstract says the graded relationship was significant at P < .001 for every studied behavior and disease. The results explicitly say there was no statistically significant dose-response relationship for stroke or diabetes.

  • Analysis sample size changes from 8,056 to 8,506

    Minor

    The exclusions paragraph says 8,056 respondents remained, but the next paragraph calls the analysis sample 8,506.

  • Abstract overstates the physical-inactivity odds ratio

    Minor

    The abstract places the increased risk for physical inactivity in a 1.4-to-1.6-fold range. Table 4 reports an adjusted odds ratio of 1.3 for four or more exposures versus none.

  • Hepatitis or jaundice odds ratio differs from Table 8

    Minor

    The prose gives an odds ratio of 2.3 for hepatitis or jaundice at four or more exposures, while Table 8 gives 2.4.

4 of 4

Cites

Flagged first, then by citations

3 of the 97 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. 1996, Morb Mortal Wkly Rep, 45, 161
  2. Harrop-Griffiths, 1988, The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse, Obstet Gynecol, 71, 589
  3. SAS Procedures Guide. SAS Institute Inc. Version 6, 3rd edition, Cary, NC: SAS Institute; 1990.

Cited by

Sorted by citations

Related

Authors
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S.
Affiliations
  • Kaiser Permanente (US)
  • Centers for Disease Control and Prevention (US)
  • Emory University (US)
  • University of Arizona (US)
Corresponding author
Felitti, Vincent J
ORCID
Venue
American Journal of Preventive Medicine
Publisher
Elsevier BV
Published
1998-05
Volume
14
Issue
4
Pages
245-258
ISSN
0749-3797 (ISSN-L)
DOI
10.1016/s0749-3797(98)00017-8
OpenAlex
W2116839388
Cited by
18,943
References
97
Citations by year
2026: 1615 · 2025: 1790 · 2024: 1720 · 2023: 1711 · 2022: 1648 · 2021: 1720 · 2020: 1565 · 2019: 1232 · 2018: 963 · 2017: 825 · 2016: 666 · 2015: 573 · 2014: 446 · 2013: 413 · 2012: 340
FWCI
57.99
Type
journal article
Language
en
Open access
Licence
Locations
  • American Journal of Preventive Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
Centers for Disease Control and Prevention (TS-44-10/12)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
  • Social Sciences › Health › Intimate Partner and Family Violence
  • Social Sciences › Safety Research › Child Welfare and Adoption
Keywords
adverse childhood experiences, childhood abuse, household dysfunction, childhood emotional abuse, child physical abuse, child sexual abuse, alcoholism, drug abuse, depression, suicide attempts, smoking, sexually transmitted infections, obesity, physical inactivity, ischemic heart disease, cancer, chronic lung disease, liver disease, cumulative exposure, leading causes of death
MeSH terms
Adult, Aged, Aged, 80 and over, California, Cause of Death, Child, Child Abuse, Family, Female, Humans, Male, Middle Aged, Surveys and Questionnaires, Risk Factors, Social Problems, Violence, Health Behavior, Logistic Models, Child of Impaired Parents, Domestic Violence

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Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-11.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.

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