The Adverse Childhood Experiences study was a landmark piece of research conducted by Kaiser Permanente and the Centres for Disease Control and Prevention (CDC) in the US in the 1980s. It was the first large scale study to look at the relationship between 10 categories of adversity in childhood and a myriad of health outcomes in adulthood, such as increased risk of depression, suicide, alcoholism, drug abuse, smoking, physical inactivity, severe obesity, sexually transmitted disease, unintentional injuries, heart disease, lung disease, liver disease, and multiple types of cancer.

Dr Vincent Felitti, head of Kaiser Permanente’s Department of Preventative Medicine, and Dr Robert Anda, an epidemiologist from the CDC, surveyed over 17,000 patients for their experiences of childhood trauma. Participants were asked about different types of childhood trauma which they referred to as ACEs. Key findings showed that:

• 60% of participants had experienced at least one ACE and 1 in 8 had experienced 4 or more ACEs.
• The higher the ACEs score, the higher the likelihood of developing long-term health problems like heart disease, stroke, cancer and Type 2 diabetes (a dose-dependence relationship).

Since the original ACE research many other studies have been conducted internationally, including here in the UK. Most of these studies uncover similar findings which increases the validity and robustness of the theory.

Repeated activation of the body’s stress-response systems (toxic stress) can cause hormonal imbalances, impair cognitive ability, and even change the way DNA is transcribed, causing ACEs to be passed down from one generation to the next. The length and frequency of exposure to toxic stress during childhood can in turn lead to health problems such as asthma, poor growth, frequent infections, learning difficulties and behavioural issues. Experiencing 4 or more ACEs is associated with significantly increased risk for 70% of the leading causes of death in adults including heart disease, stroke, cancer, respiratory disorder, Type 2 diabetes, Alzheimer’s, and suicide.

ACEs are not only associated with poorer health outcomes but a range of social and economic ones too. People with ACEs are more likely to under-perform in school, develop high-risk behaviours, and be on lower incomes. Deprivation, health, and social factors are closely related and perpetuate an inter-generational cycle of adversity.

There is research currently being conducted on the impact of different ACEs. Each individual is affected differently, depending on the length and severity of exposure, as well as personal resilience factors. ACEs only increase the risk of negative outcomes; a person may have a high ACE score without any of the associated effects. However, the key message from the evidence is that, at a population level, it is the cumulative effect of multiple ACEs which causes the most harm. Exposure to any of the ACEs, without positive attachments and trusted relationships, can lead to toxic stress and serious health and social problems in later life.

Early intervention to prevent ACEs and the worst effects of ACEs is key but it is important to recognise that is never too late to address the impact of trauma and that different individuals will require different kinds of support. The first 1000 days (pregnancy up to a child’s second birthday), pre-school, primary school age and teenage years are critical windows for intervention. However, mitigation can continue into adulthood, for example help with coping strategies and mental wellbeing support.

People can be protected from the effects of their ACEs by building resilience. The most important mitigating factor is the buffering effect of a supportive relationship with at least one trusted adult. Evidence shows that ‘5 ways to wellbeing’ is also a useful tool for building resilience. It encourages individuals to connect with others, give back to their communities, be active, take notice of what’s around them, and keep learning.

The public sector, as well as voluntary and community organisations, can work together in partnership to better support individuals and families who are struggling to cope with the causes and impacts of ACEs. This means thinking about the person’s needs more holistically, looking beyond the symptoms, and making the best use of assets and services available.

Parents want the best for their children and it is essential that the whole system is able to support this. Many parents have experienced ACEs themselves as there is evidence of intergenerational transmission. Services can support parents by seeking to identify these risks as early as possible and to respond in a better informed way.

Rather than asking as a matter of routine screening, it’s more important to be open to discussions with clients about their experiences, raising awareness of the impacts of ACEs and ways people can overcome them. Disclosing your experience of adversity takes courage and it is important that communities are compassionate in helping people in their recovery.

If you are frontline practitioner who has a relationship with a client, completing the ACEs questionnaire may be a good way to start the conversation. There is quite a lot of evidence showing that talking about trauma can contribute to recovery. It is important to ensure that those asking the questions are prepared for the response are in a position to help, and are supported themselves.

Tools are being developed in Gloucestershire and further information can be found at the www.actionaces.org  website.

We have understood that specific traumatic experiences in childhood can lead to poor outcomes for some time; we knew for example that children of parents who had mental health problems are more likely to develop problems themselves. What is new is the understanding of the cumulative effect of ACEs and the knowledge that ACEs often co-occur. Identifying one ACE should prompt a process to identify others and to uncover the root causes of adverse experiences. The ACEs approach also gives us a way to overcome the effects by building the resilience of individuals and communities.

There is a lot of good work going on to reduce the impact of harm on children, prevent, and intervene early. Mitigating the effects of ACEs needs to work alongside the traditional approaches and strengthen what is already available. Being ACE aware will complement existing services, by giving all services a common language to talk about adversity and to adopt a more holistic, trauma-informed way of working. It is not about doing new things but connecting them in different ways, seeing the big picture, and treating people with compassion (staff and clients). Empowering people involves a shift in the power dynamic.