1. Wales Adverse Childhood Experiences (ACE) Study
Dr Aideen Naughton
Service Lead Safeguarding Children Service
Public Health Wales
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2. 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

3. 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.

4. 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 was published in 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

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

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

21. 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

22. Need to understand the prevalence of ACEs in Wales to be able to focus efforts on prevention
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23. Professor Mark Bellis, Director of Policy, Research and International Development
Public Health Wales NHS Trust

24. Welsh ACE survey 2015 - Methods
National cross-sectional survey using quota sampling
Face-to-face interviews with approximately 2,000 Welsh residents aged 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

25. 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 – 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

28. ACEs increase individuals’ risk of developing health harming behaviour

29. 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.

30. 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

31. Welsh Policies Wales is pioneering a range of policies and programmes:
Building a Brighter Future: Early Years and Childcare Plan
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

32. 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

33. 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

34. Useful references
Felitti VJ, Anda RF, Nordenberg D et al ‘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 ‘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):
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):
Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS ‘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