older. Methods: Data from 2783 older male and 5018 older female respondents to the 1990 National Health Interview Survey were used. Regular physical activity was defined as participation in leisure-time physical activities 3 times or more per week for 30 minutes or more during the previous 2 weeks. Odds ratios (ORs) were estimated from multivariate logistic regression analysis. Results: Prevalence of regular physical activity was 37% among older men and 24% among older women. Correlates of regular physical activity included the perception of excellent to good health (men: OR, 1.5; 95% confidence interval [CI], 1.1-1.9; women: OR, 1.6; 95% CI, 1.3-1.9), correct exercise knowledge (men: OR, 2.4; 95% CI, 1.9-3.1; women: OR, 2.7; 95% CI, 2.2-3.4), no activity limitations (men: OR, 1.3; 95% CI, 1.0-1.6; women: OR, 1.7; 95% CI, 1.4-2.0), and not perceiving "a lot" of stress during the previous 2 weeks (men: OR, 1.7; 95% CI, 1.2-2.4; women: OR, 1.3; 95% CI, 1.0-1.6). Among those who had been told at least twice that they had high blood pressure, physician's advice to exercise was associated with regular physical activity (men: OR, 1.6; 95% CI, 1.2-2.3; women: OR, 1.5; 95% CI, 1.2-1.9). The 2 major activities among active older adults were walking (men, 69%; women, 75%) and gardening (men, 45%; women, 35%). Conclusions: Prevalence of regular physical activity is low among older Americans. Identifying the correlates of physical activity will help to formulate strategies to increase physical activity in this age group. (Arch Intern Med. 1996;156:1321-1326)

With the aging of the population, diagnosing and managing Alzheimer's disease (AD) becomes increasingly germane to the delivery of primary health care. Characterized by an insidious course, degeneration of cholinergic neurons, and abnormalities in glutamate transport, recent advances in pharmacotherapy may forestall the progression of this disease, thereby preserving the quality of life of people with AD and the well-being of those around them. Notably, despite evidencing the neuropathology characteristic of AD, some people display little evidence of cognitive impairment, thus suggesting the relevance of cognitive reserve to the manifestation of AD. Most notably, risk factors for cardiovascular disease - specifically, hypertension, diabetes, smoking, and high body mass index - also appear to be risk factors for cognitive decline. Mental and physical activity appear to exert a protective effect against cognitive deterioration in older adults and may promote the health and autonomy of persons with AD. The Alzheimer's Association and AARP have both developed programs that may help preserve the cognitive functioning of older adults, and both organizations provide resources that promote the health and safety of persons with AD and their caregivers.

Objective. Although smoking is the most important risk factor for lung cancer, nearly 10% of lung cancer is not attributable to smoking. Insights into risk factors for lung cancer other than smoking will become increasingly important, given decreasing trends in the prevalence of smoking. Prior research suggests asthma may increase the risk of lung cancer, particularly among nonsmokers. Methods. We used Cox regression analyses of data from a nationally representative sample of 9087 adults aged 30-75 years included in the NHANES II Mortality Study (1976-1992) to estimate the relative risk (RR) of death from lung cancer associated with self-reported asthma, independent of smoking. Results. Age-adjusted prevalence of smoking was 36.0%, and the age-adjusted prevalence of asthma was 6.1% (6.2% among nonsmokers) at baseline. During approximately 17 years of follow-up, 196 adults died of lung cancer (ICD-9 160-165). Among 6144 nonsmokers, the RR of lung cancer death comparing adults with asthma to those without was 1.69 (95% CI: 0.94-3.04) although the association was not statistically significant. For nonsmokers without a history of cancer, the RR was 2.53 (95% CI: 1.42-4.52). After exclusion of adults with emphysema and chronic bronchitis, the RR of lung cancer death associated with asthma was 3.54 (95% CI: 1.93-6.42). Conclusions. Consistent with prior reports, we observed an increased risk of lung cancer mortality associated with asthma among nonsmokers without a history of cancer.

Background Childhood maltreatment has been linked to a variety of changes in brain structure and function and stress–responsive neurobiological systems. Epidemiological studies have documented the impact of childhood maltreatment on health and emotional well–being. Methods After a brief review of the neurobiology of childhood trauma, we use the Adverse Childhood Experiences (ACE) Study as an epidemiological “case example” of the convergence between epidemiologic and neurobiological evidence of the effects of childhood trauma. The ACE Study included 17,337 adult HMO members and assessed 8 adverse childhood experiences (ACEs) including abuse, witnessing domestic violence, and serious household dysfunction. We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a "doseresponse" relationship of the ACE score to 18 selected outcomes and to the total number of these outcomes (comorbidity). Results Based upon logistic regression analysis, the risk of every outcome in the affective, somatic, substance abuse, memory, sexual,and aggressionrelated domains increased in a graded fashion as the ACE score increased (P <0.001). The mean number of comorbid outcomes tripled across the range of the ACE score. Conclusions The graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions.

BACKGROUND Throughout US history, US society has been characterized by its high degree of residential mobility. Previous data suggest a relationship between mobility and increased health risk, but this relationship might be confounded by unmeasured adverse childhood experiences (ACEs). OBJECTIVES To examine the relationship of childhood residential mobility to health problems during adolescence and adulthood and to determine how much these apparent relationships may result from underlying ACEs. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 8116 adults who completed a survey that included childhood residential mobility, ACEs (childhood abuse, childhood neglect, and household dysfunction), and multiple health problems. MAIN OUTCOME MEASURES Number of childhood residential moves and number of ACEs (ACE score) were assessed for relationships to depressed affect, attempted suicide, alcoholism, smoking, early sexual initiation, and teenaged pregnancy. RESULTS After adjustment for demographic variables, the risk of high residential mobility during childhood (> or = 8 moves) was 1.7- to 3.1-fold for each ACE, and increased with the number of ACEs. Compared with respondents who never moved, the odds of health risk for respondents with high mobility during childhood ranged from 1.3 (for smoking) to 2.5 (for suicide). However, when the number of ACEs was entered into multivariate models, the relationship between mobility and health problems was greatly reduced. CONCLUSIONS Adverse childhood experiences are strongly associated with frequent residential mobility. Moreover, the apparent relationship between childhood mobility and various health risks is largely explained by ACEs. Thus, previous studies showing a relationship between residential mobility and negative outcomes were likely confounded by unmeasured ACEs.

OBJECTIVE:Little information is available about the contribution of multiple adverse childhood experiences (ACEs) to the likelihood of reporting hallucinations. We used data from the ACE study to assess this relationship.METHODS:We conducted a survey about childhood abuse and household dysfunction while growing up, with questions about health behaviors and outcomes in adulthood, which was completed by 17,337 adult HMO members in order to assess the independent relationship of 8 adverse childhood experiences and the total number of ACEs (ACE score) to experiencing hallucinations. We used logistic regression to assess the relationship of the ACE score to self-reported hallucinations.RESULTS:We found a statistically significant and graded relationship between histories of childhood trauma and histories of hallucinations that was independent of a history of substance abuse. Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations.CONCLUSION:These findings suggest that a history of childhood trauma should be looked for among persons with a history of hallucinations.

Using Medicare hospital claims records and beneficiary enrollment data, the investigators describe the epidemiology of inpatient pacemaker procedures (international Classification of Diseases, Ninth Revision, Clinical Modification codes 37.80 to 37.89) in Medicare enrollees. From 1990 to 2000, the age-standardized inpatient pacemaker procedure prevalence (per 100,000 enrollees) increased from 325.4 to 504.4 in all Medicare beneficiaries. The prevalence increased significantly with age; was less for women than for men; and was less for blacks, Hispanics, and Asians than for whites. (C) 2005 by Excerpta Medica Inc.

Background Childhood maltreatment has been linked to a variety of changes in brain structure and function and stress-responsive neurobiological systems. Epidemiological studies have documented the impact of childhood maltreatment on health and emotional well-being. Methods After a brief review of the neurobiology of childhood trauma, we use the Adverse Childhood Experiences (ACE) Study as an epidemiological "case example" of the convergence between epidemiologic and neurobiological evidence of the effects of childhood trauma. The ACE Study included 17,337 adult HMO members and assessed 8 adverse childhood experiences (ACEs) including abuse, witnessing domestic violence, and serious household dysfunction. We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a "dose-response" relationship of the ACE score to 18 selected outcomes and to the total number of these outcomes (comorbidity). Results Based upon logistic regression analysis, the risk of every outcome in the affective, somatic, substance abuse, memory, sexual, and aggression-related domains increased in a graded fashion as the ACE score increased (P < 0.001). The mean number of comorbid outcomes tripled across the range of the ACE score. Conclusions The graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions.

Objective: Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence.Method: We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors.Results: Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p < .0001), confirming the statistical interrelatedness of ACEs.Conclusions: The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes. (C) 2004 Elsevier Ltd. All rights reserved.

In recent years, the prevalence of childhood emotional abuse has surpassed other forms of maltreatment. Childhood verbal abuse (CVA) is a key attribute of emotional abuse, yet CVA is not recognized as its own form of maltreatment and thus, has not received adequate attention. Clear terminology, definitions, and measures are needed to aid in assessing the occurrence and impact of CVA for its recognition and prevention.We aim to synthesize the evidence on the terms, definitions, and measurements of CVA and identify outcomes associated with CVA.A systematic review focused on adult perpetration of CVA among children and adolescents using clinical, community-based, and population-based samples.The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed and four databases were utilized in May 2022: PsycINFO, MEDLINE, EMBASE, and ProQuest. A total of 149 quantitative and 17 qualitative studies were identified.Across studies reviewed, the most common perpetrators of CVA were parents, mothers, and teachers. Definitional themes for CVA included negative speech volume, tone, and speech content, and their immediate impact. The most frequent measures cited were Adverse Childhood Experiences Study (ACE) Questionnaire and the Conflict Tactics Scale (CTS); 50 % used self-created measures. CVA was associated with a range of internalizing and externalizing outcomes across the lifespan.Recognizing CVA as a form of maltreatment will be a starting point for its identification and prevention. Primary prevention of CVA using trauma-informed approaches must include adult training on the importance of safety, support, and nurturance during verbal communication with children.

Background: Research examining the association between childhood abuse and depressive disorders has frequently assessed abuse categorically, thus not permitting discernment of the cumulative impact of multiple types of abuse. As previous research has documented that adverse childhood experiences (ACEs) are highly interrelated, we examined the association between the number of such experiences (ACE score) and the risk of depressive disorders. Methods: Retrospective cohort study of 9460 adult health maintenance organization members in a primary care clinic in San Diego, CAwho completed a survey addressing a variety of health-related concerns, which included standardized assessments of lifetime and recent depressive disorders, childhood abuse and household dysfunction. Results: Lifetime prevalence of depressive disorders was 23%. Childhood emotional abuse increased risk for lifetime depressive disorders, with adjusted odds ratios (ORs) of 2.7 [95% confidence interval (CI), 2.3–3.2] in women and 2.5 (95% CI, 1.9–3.2) in men. We found a strong, dose–response relationship between the ACE score and the probability of lifetime and recent depressive disorders (P< 0.0001). This relationship was attenuated slightly when a history of growing up with a mentally ill household member was included in the model, but remained significant (P< 0.001). Conclusions: The number of ACEs has a graded relationship to both lifetime and recent depressive disorders. These results suggest that exposure to ACEs is associated with increased risk of depressive disorders up to decades after their occurrence. Early recognition of childhood abuse and appropriate intervention may thus play an important role in the prevention of depressive disorders throughout the life span. Published by Elsevier B.V.

Background—The purpose of this study was to assess the relation of adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, to the risk of ischemic heart disease (IHD) and to examine the mediating impact on this relation of both traditional IHD risk factors and psychological factors that are associated with ACEs. Methods and Results—Retrospective cohort survey data were collected from 17 337 adult health plan members from 1995 to 1997. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACE–IHD relation and the mediating impact of IHD risk factors in this relation. Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with ≥7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE–IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. We observed significant association between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7. Conclusions—We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

OBJECTIVES:Few reports address the impact of cumulative exposure to childhood abuse and family dysfunction on teen pregnancy and consequences commonly attributed to teen pregnancy. Therefore, we examined whether adolescent pregnancy increased as types of adverse childhood experiences (ACE score) increased and whether ACEs or adolescent pregnancy was the principal source of elevated risk for long-term psychosocial consequences and fetal death.DESIGN, SETTING, AND PARTICIPANTS:A retrospective cohort study of 9159 women aged > or = 18 years (mean 56 years) who attended a primary care clinic in San Diego, California in 1995-1997.MAIN OUTCOME MEASURE:Adolescent pregnancy, psychosocial consequences, and fetal death, compared by ACE score (emotional, physical, or sexual abuse; exposure to domestic violence, substance abusing, mentally ill, or criminal household member; or separated/divorced parent).RESULTS:Sixty-six percent (n = 6015) of women reported > or = 1 ACE. Teen pregnancy occurred in 16%, 21%, 26%, 29%, 32%, 40%, 43%, and 53% of those with 0, 1, 2, 3, 4, 5, 6, and 7 to 8 ACEs. As the ACE score rose from zero to 1 to 2, 3 to 4, and > or = 5, odds ratios for each adult consequence increased (family problems: 1.0, 1.5, 2.2, 3.3; financial problems: 1.0, 1.6, 2.3, 2.4; job problems: 1.0, 1.4, 2.3, 2.9; high stress: 1.0, 1.4, 1.9, 2.2; and uncontrollable anger: 1.0, 1.6, 2.8, 4.5, respectively). Adolescent pregnancy was not associated with any of these adult outcomes in the absence of childhood adversity (ACEs: 0). The ACE score was associated with increased fetal death after first pregnancy (odds ratios for 0, 1-2, 3-4, and 5-8 ACEs: 1.0, 1.2, 1.4, and 1.8, respectively); teen pregnancy was not related to fetal death.CONCLUSIONS:The relationship between ACEs and adolescent pregnancy is strong and graded. Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying ACEs rather than adolescent pregnancy per se.

Objective: This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction.Methods: Retrospective cohort study data were collected from 17-133,7 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score).Results: CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < .05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < .01).Conclusions: CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs. (C) 2003 Elsevier Science Ltd. All rights reserved.

Objective: To examine the relationship of adverse childhood experiences (ACES), including abuse, neglect, and forms of household dysfunction, to the risk of liver disease by assessing the role of risk behaviors, such as substance abuse and high-risk sexual activity, as mediators of the ACEs-liver disease relationship.Methods: Retrospective cohort study data were collected from 17337 adult health plan members through a survey. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACEs-liver disease relationship and the impact of the mediators in this relationship.Results: Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). The number of ACEs (ACE score) had a graded relationship to liver disease (P<.001). Compared with persons with no ACEs, the adjusted odds ratio of ever having liver disease among persons with 6 or more ACEs was 2.6 (P<.001). The ACE score also had a strong graded relationship to risk behaviors for liver disease. The strength of the ACEs-liver disease association was reduced 38% to 50% by adjustment for these risk behaviors, suggesting they are mediators of this relationship.Conclusions: The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACES on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.

International Journal of Geriatric PsychiatryVolume 18, Issue 2 p. 185-186 Research Letter Medication-induced emergency hospitalizations for psychiatric disorders among older adults in the US Daniel P. Chapman, Corresponding Author Daniel P. Chapman [email protected] Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USAEmerging Investigations and Analytic Methods Branch, Division of Adult and Community Health, NCCDPHP, CDC, 4770 Buford Highway NE, Mailstop K-67, Atlanta, GA 30341, USA.Search for more papers by this authorGlenn W. Currier, Glenn W. Currier University of Rochester Medical Center, Rochester, NY, USASearch for more papers by this authorJoan K. Miller, Joan K. Miller Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USASearch for more papers by this authorRobert F. Anda, Robert F. Anda Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USASearch for more papers by this author Daniel P. Chapman, Corresponding Author Daniel P. Chapman [email protected] Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USAEmerging Investigations and Analytic Methods Branch, Division of Adult and Community Health, NCCDPHP, CDC, 4770 Buford Highway NE, Mailstop K-67, Atlanta, GA 30341, USA.Search for more papers by this authorGlenn W. Currier, Glenn W. Currier University of Rochester Medical Center, Rochester, NY, USASearch for more papers by this authorJoan K. Miller, Joan K. Miller Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USASearch for more papers by this authorRobert F. Anda, Robert F. Anda Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USASearch for more papers by this author First published: 04 February 2003 https://doi.org/10.1002/gps.780Citations: 5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume18, Issue2February 2003Pages 185-186 RelatedInformation

Information about the relationship of experiencing abuse or witnessing domestic violence in childhood to the risk of intimate partner violence (IPV) in adulthood is scant. The relationship of childhood physical or sexual abuse or growing up with a battered mother to the risk of being a victim of IPV for women or a perpetrator for men was studied among 8,629 participants in the Adverse Childhood Experiences Study conducted in a large HMO. Each of the three violent childhood experiences increased the risk of victimization or perpetration of IPV approximately two-fold. A statistically significant graded relationship was found between the number of violent experiences and the risk of IPV. Among persons who had all three forms of violent childhood experiences, the risk of victimization and perpetration was increased 3.5-fold for women and 3.8-fold for men. These data suggest that as part of risk assessment for IPV in adults, screening for a history of childhood abuse or exposure to domestic violence is needed.

OBJECTIVE Illicit drug use is identified in Healthy People 2010 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. METHODS 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 categories: or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use. RESULTS 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 >or=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. CONCLUSIONS 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.

OBJECTIVE This study examined the prevalence of a history of various combinations of childhood maltreatment types (physical abuse, sexual abuse, and witnessing of maternal battering) among adult members of a health maintenance organization (HMO) and explored the relationship with adult mental health of the combinations of types of childhood maltreatment and emotional abuse in the childhood family environment. METHOD A total of 8,667 adult members of an HMO completed measures of childhood exposure to family dysfunction, which included items on physical and sexual abuse, witnessing of maternal battering, and emotional abuse in the childhood family environment. The adults' current mental health was assessed by using the mental health scale of the Medical Outcomes Study 36-item Short-Form Health Survey. RESULTS The prevalences of sexual abuse, physical abuse, and witnessing of maternal violence were 21.6%, 20.6%, and 14.0%, respectively, when the maltreatment types were considered separately. Among respondents reporting any of the maltreatment types, 34.6% reported more than one type of maltreatment. Lower mean mental health scores were associated with higher numbers of abuse categories (mean=78.5, 75.5, 72.8, and 69.9 for respondents with no, one, two, and three abuse types, respectively). Both an emotionally abusive family environment and the interaction of an emotionally abusive family environment with the various maltreatment types had a significant effect on mental health scores. CONCLUSIONS Childhood physical and sexual abuse, as well as witnessing of maternal battering, were common among the adult members of an HMO in this study. Among those reporting any maltreatment, more than one-third had experienced more than one type of maltreatment. A dose-response relation was found between the number of types of maltreatment reported and mental health scores. In addition, an emotionally abusive family environment accentuated the decrements in mental health scores. Future research examining the effects of childhood maltreatment on adult mental health should include assessments of a wide range of abusive experiences, as well as the family atmosphere in which they occur.