1Public Health Wales, 2Bangor University Translating evidence on adverse childhood experiences (ACEs) into practice: an example of using an ACE lens for policy development in South Wales Kat Ford1,2, Kath Ashton1, Karen Hughes1,2, Alisha Davies1, Janine Roderick1. 1Public Health Wales, 2Bangor University

Adverse Childhood Experiences (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) Bellis et al 2016 The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviours. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. The ACE score is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course

Prevalence of ACEs in Wales In 2015 Wales’ prevalence study into ACEs was completed. This was a nationally representative household survey with 2,000 adult residents aged 18-69. The study identified that substantial proportions of the Welsh population have suffered abuse, neglect and other ACEs during their childhood. 14% of the Welsh adult population are estimated to have experienced four or more ACEs.  

ACEs and poor outcomes Compared with people with no ACEs, those with 4+ were:- 2 x more likely to be diagnosed with a chronic disease 3 x more likely to develop Heart disease more likely to have attended A&E 4 x more likely to be a high-risk drinker 6 x more likely to have low mental wellbeing 11 x more likely to have smoked cannabis 14 x more likely to have been a victim of violence 15 x more likely to have perpetrated violence 20 x more likely to have been incarcerated Compared with someone who has no ACEs, having 4 or more increases the risk for a range of poor outcomes Individuals with 4 or more ACEs were more likely to undertake a range of health harming behaviours, i.e. Were 11 times more likely to smoke cannabis Were more likely to experience increased morbidity and mortality, poor mental well-being And were more likely to perpetrate violence. 20 times more likely to be incarcerated at some point in their lifetime.

Impact from preventing ACEs in future generations The study found that preventing ACEs for future generations can lessen health harming behaviours – reduce heroin crack cocaine use by 66% Reduce levels of smoking and e-cigarette use by a quarter. Reduce criminal justice outcomes by approx 60%. Also reduce levels of early sex and unintended teenage pregnancy by over a third. This is utopia but we can not magically take all children out of these situations. Demonstrate a focus on what impact generating change would have

The ACE findings were published and are publicly facing documents The findings were clearly and precisely presented using infographics to ensure they were widely understandable and widely disseminated across Wales and beyond. This led to them being picked up and integrated into a number of plans and influencing policy

Use of evidence in Wales to promote partnership working to prevent at a local level Well-being of future generations (Wales) Act 2015 PHW strategic plan ‘Support families and parents to reduce adverse childhood experiences which can have lifelong effects’ Taking Wales Forward 2016-2021 Welsh Government South Wales Police & Crime reduction plan ACE findings have been utilised and align with Welsh policy including the Well-being of future generations Act in Wales. The Well-being of Future Generations Act is about improving the social, economic, environmental and cultural well-being of Wales, enabling Wales to more prosperous, healthy, cohesive and resilient. This ground-breaking legislation has a focus on prevention, and ACEs will be an important measure of success. PHW refer to ACEs in their strategic plan and in Wales there is a clear political commitment to reduce ACEs from the Welsh Government. There has been a commitment by the police where the focus has been on the police response to vulnerable individuals who may have experiences ACEs. Critical in driving multi-agency action. The South Wales Police and Crime Plan has a focus on early intervention and prompt and positive action; and looks to prevent crime, protect vulnerable people, improve the connection between the police and the community, and spend money wisely. Priority 3 of the plan states ‘We will work to protect the most vulnerable in our communities’ South Wales Police have used the ACE study findings to drive practice and change at a local level.

Using an ACE lens for policy development in South Wales: The Early Intervention and Prevention project In 2015, 89% of South Wales Police contact related to complex welfare, public safety and vulnerability issues Police are well-placed to identify individuals at risk of ACEs Excess demand: in 2016 >60,000 safeguarding referrals Vision: The police and partners will have the right knowledge, skills and support to identify and respond appropriately and effectively to early indicators of harm and vulnerability, breaking the generational cycle of crime. In south Wales 89% of contact with the public is in relation to complex welfare, public safety and vulnerability issues, and as such the police are well-placed to identify individuals at risk of ACEs. Following an 2015 inspection by HMIC which identified a need to improve the response to protecting vulnerable people, South Wales Police introduced a new definition for vulnerability. The definition categorises a person as vulnerable if they are unable to care or protect themselves from harm or exploitation. The current system used by South Wales Police for the identification and referral of safeguarding is the Public Protection Notification, or PPN, process. Staff complete PPNs for individuals identified as vulnerable and submit to Police Public Protection Units within 24 hours, where the case is risk assessed and shared with partner agencies where appropriate. PPNs are categorised as relating to one or more of the following concerns: domestic violence and abuse, child concern and child sexual exploitation, vulnerable adult, mental health, honour-based violence More than 60,000 PPNs were submitted to PPUs in 2016, yet the majority of PPNs shared with social services do not reach the thresholds for support to be put in place.

Response to vulnerability by South Wales Police Research: ~400 hrs observations Focus groups and interviews with police staff Interviews with statutory partners Focus groups with public Recommendations for change: Pilot a multi agency, early intervention approach to vulnerability with NPTs Deliver training on ACEs to frontline police Develop an ACE informed approach to the existing processes for safeguarding referrals Develop a 24/7 ACE informed approach to responding to vulnerability Assist SWP with the development of their well-being agenda 43 observations of operational policing ~400 hours 27 interviews and 7 focus groups with police officers and staff 3 focus groups with the public 7 interviews with partner agencies

Responding to ACEs across other sectors

Thank you Dr Kat Ford Katharine.ford@Bangor.ac.uk