1. Adverse Childhood Experiences (ACE) A Place Based Approach
Designated Safeguarding Leads Networks 16,17,18th October 2017
Sarah Doran
Strategic Lead, Population Health and Wellbeing, Manchester Health and Care Commissioning
Dr Shirley Woods-Gallagher
Strategic Lead, Reform and Innovation, Manchester City Council

2. What our JSNA is telling us about Manchester
Life expectancy – significantly lower than England average (75.5 years men, 80 years women)
Overall premature mortality (deaths under 75) – worst in country
Premature death from:
Heart disease and stroke – worst in country
Respiratory problems – 2nd highest in country
Cancer – 3rd highest in country
Smoking attributable deaths – highest in country

3. The ACES Study
Adverse Childhood Experiences Study - researchers at the CDC and Kaiser Permanente in US in the mid 1990s.
They asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs
Asked 10 questions

4. 5 indirect ACE questions
sexual abuse by parent/caregiver
emotional abuse by parent/caregiver
physical abuse by parent or caregiver
physical neglect by parent or caregiver
emotional neglect by parent or caregiver
5 indirect ACE questions
6. parent/caregiver addicted to alcohol/other drugs
7. witnessed abuse in the household
8. family member in prison
9. family member with a mental illness
10. parent/caregiver disappeared through abandoning family/ divorce

5. ACE Study Findings ACES are incredibly common
2) There was a dose-response relationship between ACEs and health outcomes - the higher your ACE score, the worse your health outcomes.
They found:
ACEs are incredibly common.
US study - 67% percent of the population had at least one ACE and 12.6 % had four or more ACEs.
Studies in UK estimate 9% -12%, of people experience 4 or more ACEs
If we apply this to Manchester – we estimate that 47,000 – 65,000 people living in Manchester will be affected by 4 or more ACEs
There was a dose-response relationship between ACEs and health outcomes:
the higher your ACE score, the worse your health outcomes.
E.g. For someone with an ACE score of four or more he or she is:
two and a half times more likely to develop chronic obstructive pulmonary disease (COPD)
A person with an ACE score of seven or more had
triple the lifetime risk of lung cancer and chronic obstructive pulmonary disease
three and a half times the risk of ischemic heart disease

6. ACE Research (Felitti et al 1998)
Over 12x
increased risk
4 or more adverse childhood exposures significantly increase the odds of a person:
By nearly 5x increased risk
Over 7x
increased risk
Attempting suicide
Being addicted to alcohol
Using illicit drugs
By 2.5x
9,508 Americans completed an ACE questionnaire as part of standardised medical evaluation.
Having sexually transmitted infections

7. Research Findings on ACE Compared with people with no ACEs those with a score of 4 or more were found - 2 x as likely to binge drinking and have a poor diet - 3 x more likely to be a current smoker - 5 x more likely to have had sex under the age of 16 years - 6 x more likely to have had/caused an unplanned pregnancy - 7 x more likely to be involved in violence in the last year - 11 x more likely to have used drugs and/or been in prison

8. The ACE Study Summary of Findings:
Adverse Childhood Experiences (ACEs) are very common, but largely unrecognised.
ACEs are strong predictors of later social functioning, well-being, health risks, disease, medical costs, and death.
ACEs are thus the basis for much of adult medicine and of many major public health and social problems.
Adverse childhood experiences are interrelated, not solitary.
This combination makes Adverse Childhood Experiences the leading determinant of the health, social, and economic well-being of USA. 5

14. The Science
We now understand better than ever before how exposure to early adversity affects the developing brains and bodies of children.
It affects areas like the nucleus accumbens, the pleasure and reward centre of the brain that is implicated in substance dependence.
It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning.
And on MRI scans, we see measurable differences in the amygdala, the brain's fear response centre.
So there are real neurologic reasons why people exposed to high doses of adversity are more likely to engage in high-risk behaviour, and that's important to know.
But it turns out that even if you don't engage in any high-risk behaviour, you're still more likely to develop heart disease or cancer.
The reason for this is do with the brain's and body's stress response system that governs our fight-or-flight response.
How does it work? Example from Dr Nadine Burke
Example of walking in the forest and you see a bear.
Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says,
"Release stress hormones! Adrenaline! Cortisol!"
And so your heart starts to pound, your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear.
And that is wonderful if you're in a forest and there's a bear.
But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being life-saving to health-damaging.
Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing.
High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.

16. Repeat cycle of…

18. So, now we know and understand the impact of ACEs…
How do we use this for prevention and treatment?
Why is routine enquiry needed?

20. Workforce to be trained at Place level
Integrated Neighbourhood Management Team
Health & Social Care
Substance Misuse
Adult Mental Health
Behaviour Support Staff in Schools
Factory Youth Zone
Early Help including Early Years

21. Core training components
ACE awareness
Routine enquiry about adversity in childhood
Trauma-informed practice
Resilience
Importance of evaluating work and using the findings to inform practice
Role of ACE champions
Pathways for the most complicated targeted and specialist disclosures

22. Potential benefits for Manchester
Evaluate the impact of systemic practice change at a systems level
Evaluate the health and economic of ACE for the first time at this level
Improved Early Years outcomes
Reducing teenage pregnancy and supporting teenage parents
Reducing obesity prevalence, smoking, drinking alcohol and drug misuse
Improved mental health
Improved workforce training offer on the frontline and % of workforce addressing own ACE related problems
Improved school attainment
Reduction in police calls out for unmet social need
Improved commissioning information on what matters to people with lived experience of residents

23. Summary Transferable learning from delivering differently
Recovery aspect and resilience is key
Fits with signs of safety work
Need trauma informed workforce confident in using routine enquiry – wider than social care and safeguarding
Need to act as systems leaders to raise awareness of ACEs and support the change we’re proposing

24. Videos About ACE Science and Impact in Practice
Password for Vimeo link is Wednesday