Wales Adverse Childhood Experiences (ACE) Study Dr Aideen Naughton Service Lead Safeguarding Children Service Public Health Wales Insert name of presentation on Master Slide--

Early Intervention Foundation 2015 Early Intervention Services Acute or Statutory Services ££££s £££s £17 billion £s Early Intervention is key. A report in 2015 by the Early Intervention Foundation found that nearly £17 billion per year is spent in England and Wales on a range of acute or statitory services that are required when children and young people experience significant difficulties in life. These services are of course in themselves valuable and important and the need for them will never be eliminated, fiscal challenges we all face mean that we must minimize the demand for them as much as possible by intervening early to prevent maltreatment impacts and reduce costs to the public purse. Early Intervention Foundation 2015 Spending on late intervention :how we can do better for less

WHO European Report on preventing child maltreatment 2013 Leads to premature death at least 850 children pa under 15yrs Sexual abuse(18 million)physical abuse (44 million) emotional abuse(55 million) Rates of homicides in low and middle income countries more than x 2 high income countries PTSD in 1 in 4 abused children Accounts for almost 25% mental disorders Emerging evidence suggests economic and social costs run into 10s of billions of Euros Taken from the World Health Organization European Report on preventing child maltreatment published in 2013 which looked across participating countries from the 28 European Union countries.

WHO European Prevention Action Plan Goal: To reduce the prevalence of child maltreatment by implementing programmes that address risk and protective factors, including social determinants Target: Reduce the prevalence of child maltreatment and child homicide rates by 20% by 2020 The subsequent prevention Action plan entitled Investing in Children: The European Child Maltreatment prevention Action plan 2015-2020 was published in 2015. It was developed through a consultative process, guided by the standing committee of the Regional Committee WHO Europe. The evidence base which informs the plan is to be found in the WHO European Report on preventing Child Maltreatment. It focuses on priority actions and interventions that are informed by evidence and that will bring benefits which will outweigh any cost of investment. Investing in children: the European child maltreatment prevention action plan 2015-2020

WHO European Prevention Action Plan Strengthen data collection to show and monitor the extent of the problem Develop comprehensive national action plans for violence prevention Integrate violence prevention into other health platforms Implement evidence informed programmes Upgrade the quality of services for victims Undertake population surveys to underpin national planning and evaluation. Surveys for CM only in 60% of countries and elder abuse in 32% 2.needs to involve multi sectorial approach with a lead agency for accountability and monitoring Integrate into child health, home visitation, midwifery and mental health services. Violence is an unwanted outcome of risky alcohol consumption and synergies with alcohol reduction programmes need to be reinforced..This is probably where the work that JANINE RODERICK with PHW and the violence surveillance data mapping comes in Action plans need to contain the 18 solutions for violence prevention identified though systematic reviews of the evidence supported by evidence of effectiveness. Obvious! Examples are the banning of corporal punishment in 90% of countries but only 50% enforce the law. Laws against elder abuse need enactment especially in view of the changing demographic. Social marketing campaigns strengthen pubic understanding of and support for these laws Investing in children: the European child maltreatment prevention action plan 2015-2020

WHO European Prevention Action Plan 6. Improve the enforcement and quality of existing laws 7. Build health systems capacity for violence prevention 8. Focus on equity and the life course 6. Examples are the banning of corporal punishment in 90% of countries but only 50% enforce the law. Laws against elder abuse need enactment especially in view of the changing demographic. Social marketing campaigns strengthen pubic understanding of and support for these laws 7. Surveillance and programming 8. As early life violence affects physical and mental health and social attainment across the life course, investing in preventing violence on children should be a priority Investing in children: the European child maltreatment prevention action plan 2015-2020

Legacy for Adult Health Higher rates of healthcare use Higher healthcare costs More reported symptoms More chronic pain syndromes Overall less satisfaction with their health Survivors of childhood abuse and neglect often suffer from health problems long after the abuse has ended

Children raised in environments where violence, assault and abuse are common are more likely to develop such traits themselves as these behaviours are seen as normal (i.e. normalised); leaving them more likely to both commit violent acts and/or be the victim of such acts in adulthood. The psychological problems associated with exposure to ACEs can leave individuals with feelings of low self-worth and a propensity for behaviours offering short-term relief at the expense of longer-term health. This combination leaves affected individuals prone to adopting harmful behaviours such as smoking, harmful alcohol consumption, poor diets and early sexual activity. It can be contagious.............

Consequences for Adulthood The Adverse Childhood Experiences (ACE)- US 50+ Publications ACE score : increased rates Alcoholism and alcohol abuse Chronic obstructive pulmonary disease Depression Health-related quality of life Ischemic heart disease Liver disease The Adverse Childhood Experiences (ACE) Study is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego. Adverse experiences child abuse- physical, emotional sexual, Neglect-( emotional &physical), House hold dysfunction, mother treated violently , household substance misuse, household mental illness, parental separation or divorce, parent in prison ACEs have significance in their own right as risk factors for later adverse health outcomes but they are cumulative with the poorest outcomes directly correlated with an increasing number of ACEs , especially for 4 or more. These are just a few of the commonest adult health problems impacted by 4+ ACEs

What are ACEs? ACEs are stressful experiences occurring during childhood that directly harm a child (e.g. sexual or physical abuse) or affect the environment in which they live (e.g. growing up in a house with domestic violence). ACEs and their association with health-harming behaviours in the Welsh adult population

What are ACEs? Verbal abuse Physical abuse Sexual abuse Incarceration Within this ACE survey the researchers asked about whether any of the following had been experienced before the age of 18: Domestic violence Mental illness Alcohol abuse Drug abuse Parental separation ACEs and their association with health-harming behaviours in the Welsh adult population

The Brain and Maltreatment The most sensitive and responsive organ to the Environment Impact of stress Impact of deprivation Timing of insult Duration of trauma We know that research has begun to show that adverse care giving experiences can affect brain structures and how these may in turn impact on psychological and emotional development. There is now reliable evidence that childhood adversity is associated with atypical development of that part of the brain which controls the release of stress hormones. The 4 points (in bullets) are important considerations

Brain Development - The Critical Years First 2 years - baby’s brain grows from 25% to 80% of adult size Development continues in childhood learning empathy, trust and community This is why the first 1000 days are critical, although there are opportunities across childhood and adolescence our focus to build strong foundations should be the first 1000 days Early years programme

The Impact of ACEs on Brain Development At Rest Threat Fight or Flight Exhausted Recovery Healthy response ACEs Fixed Allostatic load Chronic Stress from ACEs over-develop ‘life-preserving’ part of the brain. ACEs are known to have direct and immediate effects on a child’s health through, for instance, physical injury to a child who is abused. Exposure to threat and harm produces a trauma response Chronic traumatic stress in early life alters how a child’s brain develops and can fundamentally alter nervous, hormonal and immunological system development .  This can result in individuals whose systems are ‘locked’ into a higher state of alertness; permanently prepared for further trauma. Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014

Brain Development - The Critical Years First 2 years - baby’s brain grows from 25% to 80% of adult size Development continues in childhood learning empathy, trust and community This is why the first 1000 days are critical, although there are opportunities across childhood and adolescence our focus to build strong foundations should be the first 1000 days Early years programme

Always prepared to fight or flee Anxious Always prepared to fight or flee Disengaged During school years, the same individuals may display a heightened emotional state of anxiety (ready to fight or always prepared to run away) and consequently be distracted from educational pursuits, resulting in poor educational attainments. Poor learner

Impact of Early Maltreatment on the Neurological System Maltreatment and trauma in early years results in: Overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation; hyperactivity); Deficits in cortical (problem-solving) and limbic function (empathy) To summarise some key points from the neuroscience research on the impact of early maltreatment on the brain: There may be overdevelopment of the neurophysiology of the brainstem and midbrain outwardly shown by anxiety; impulsivity; poor affect(emotion or mood) regulation; hyperactivity and /or deficits in cortical function with problem solving difficulties and deficits in limbic function( where memories are laid down and the amygdala/area which responds to threat is located) as problems with developing empathy.

Adverse Childhood Experiences ACEs - The Life Course Developed from Felitti et al. 1998 DEATH LIFE COURSE Early Death Non Communicable Disease, Disability, Social Problems, Low Productivity Adopt Health Harming Behaviours and Crime Social, Emotional and Learning Problems Such physiological changes increase the wear and tear (allostatic load) on their body; increasing risks of premature ill health such as cancer, heart disease and mental illness. Adopting health harming behaviors as coping mechanisms, smoking alcohol, drug use Disrupted Nervous, Hormonal and Immune Development ACEs Adverse Childhood Experiences BIRTH

In the earlier studies they found a stepwise correlation between the ACE score and the % rate of alcoholism in middleage. Felitti V.J. 1998

A similar pattern was found for anti depressant use at age 50. Felitti V.J. 1998

In terms of self efficacy, empowerment and independence , these correlations between the ACE score and impaired worker performance are the most chilling for the toll adversity has on families. Felitti V.J. 1998

Need to understand the prevalence of ACEs in Wales to be able to focus efforts on prevention Insert name of presentation on Master Slide

Professor Mark Bellis, Director of Policy, Research and International Development Public Health Wales NHS Trust

Welsh ACE survey 2015 - Methods National cross-sectional survey using quota sampling Face-to-face interviews with approximately 2,000 Welsh residents aged 18-69 years Of those eligible to participate, just under half agreed to take part Questions about their current health behaviours and their exposure to ACEs using an internationally validated ACE questionnaire. A respondent’s ACE score is based on a count of the number of different types of adverse events they experienced (range 0 to 9). This does not account for reoccurring events or the duration of events. Public Health Wales in collaboration with Liverpool John Moores University Based on similar methodology to other ACE surveys e.g. England and European Quota sampling used – age, sex and deprivation using WIMD and selecting a random sample of LSOAs by LHB ACEs and their association with health-harming behaviours in the Welsh adult population

Results – Overall prevalence of ACEs For every 100 adults in Wales, 47 have suffered at least one ACE during their childhood and 14 have suffered 4 or more. 0 ACEs 53% 1 ACE 20% 2-3 ACEs 13% 4+ ACEs 14% Based on population adjusted prevalence in adults aged 18-69 – age, sex and WIMD In comparison to England, Wales has a higher proportion of adults who have experienced 4 or more ACEs. Overall, 14% of the Welsh adult population are estimated to have experienced 4 or more ACEs, compared to 9% in England. ACEs and their association with health-harming behaviours in the Welsh adult population

ACEs increase individuals’ risk of developing health harming behaviour

So turning these figures around if we could prevent these Welsh citizens from having any ACEs this is the impact oit would have on these health harming behaviours in terms of % reduction.

Breaking the ACE cycle in Wales Focus on resilience to build the protection factors which guard individuals within times of adversity How? Identify and intervene where children may already be victims of CAN or living in adverse environments Better equip parents and care givers with the necessary skills to avoid ACEs within the home and to promote development of social emotional well being and resilience in the child Ensure that domestic abuse, substance use and other mental and behavioral problems in the family setting are identified, addressed to minimise the impact on children Welsh policies including the Future Generations Bill provide the legitimacy for targeted activity towards primary prevention of adverse experiences in the early years United in Improving Health provide the opportunity for the essential co-production and co-ordination of assets, investments and activity in order to make action happen. MOU – multi-agency working focusing on shared resources and prevention ACEs and their association with health-harming behaviours in the Welsh adult population

Welsh Policies Wales is pioneering a range of policies and programmes: Building a Brighter Future: Early Years and Childcare Plan 2013-2023 The Healthy Child Wales Programme Promotion behaviours to support positive parent child relationships resulting in secure emotional attachment Promotion of positive maternal and family emotional health and resilience Tackling Poverty programmes such as Flying Start and Families first Welsh policies including the Future Generations Bill provide the legitimacy for targeted activity towards primary prevention of adverse experiences in the early years. Impact of Families First funded projects and whether there is a strong evidence base underpinning them linked to child adversity prevention. United in Improving Health provide the opportunity for the essential co-production and co-ordination of assets, investments and activity in order to make action happen. MOU – multi-agency working focusing on shared resources and prevention ACEs and their association with health-harming behaviours in the Welsh adult population

Breaking the ACE cycle in Wales United in Improving Health – co-production and coordination of assets, investment and activity in Wales to accomplish a shared set of goals E.g improving outcomes in the early years with a focus on the first two years of life Well-being of Future Generations (Wales) Act 2015 7 goals including a resilient Wales, a healthier Wales, a more equal Wales ACEs and their association with health-harming behaviours in the Welsh adult population

Next steps.. Further results will be published later this year Future reports will cover the impact of ACEs on chronic ill health, use of health and social care services, premature mortality and mental well-being in Welsh adults. Welsh policies including the Future Generations Bill provide the legitimacy for targeted activity towards primary prevention of adverse experiences in the early years United in Improving Health provide the opportunity for the essential co-production and co-ordination of assets, investments and activity in order to make action happen. MOU – multi-agency working focusing on shared resources and prevention ACEs and their association with health-harming behaviours in the Welsh adult population

Useful references Felitti VJ, Anda RF, Nordenberg D et al. 1998. ‘Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.’ American Journal of Preventive Medicine 14:245–258. Anda RF, Felitti VJ and Bremner JD. 2006. ‘The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology’ European Archives of Psychiatry and Clinical Neuroscience 256(3):174-186. Bellis MA, Hughes K, Leckenby N, Perkins C and Lowey H. 2014a. ‘National Household Survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England’. BMC Medicine 12:72. Bellis M, Hughes K, Leckenby N, et al. 2014b. ‘Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in the European region’. Bulletin of the World Health Organisation 92(9):621-696. Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. 2004. ‘The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial outcomes, and fetal death.’ Pediatrics 113(2):320–327. ACEs and their association with health-harming behaviours in the Welsh adult population