Adverse ChildhoodAdverse ChildhoodExperiences in Wales

Professor Mark A. BellisDirector of Policy, Researchand InternationalDevelopmentPublic Health Wales

Early Life Experience and The BrainChildhood

• First 2 years - baby’s brain grows from25% to 80% of adult size

• Critical restructuring continues throughchildhood for empathy, trust, community

Fight or Run AwayHealth FixedAllostatic load

Chronic Stress from ACEs• Violence - over-develop ‘life-preserving’ brain

NEUTRAL CUES LOOK THREATENING• School – anxious, disengaged, poor learner

At Rest

Threat Exhausted

RecoveryAt Rest

ACEs

Allostatic load

Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014

How many adults in Wales have ACEs

Child Maltreatment

Childhood Household includedChildhood Household included

For every 100 adults in Wales, 47 have suffered at leastone ACE and 14 have suffered four or more.

Adverse Childhood Experiences ACEs - The Life Course

Early Death

Adopt Health HarmingBehaviours and Crime

Non Communicable Disease, Disability,Social Problems, Low Productivity

Lif

eC

ours

eDeath

Social, Emotional andLearning Problems

Disrupted Nervous, Hormonaland Immune Development

ACEs AdverseChildhood Experiences

Lif

eC

ours

e

Birth

Developed from Felitti et al. 1998Bellis 2016

Compared with peoplewith no ACEs, thosewith 4+ ACEs were:

National Study of ACEs in Wales (18-69 years)

times more likely to be a high risk drinker4

INDEPENDENT OF POVERTYBellis et al. 2015, n=2028

times more likely to have had or caused a teenage pregnancy6

times more likely to have committed violence in last 12 months15

times more likely to have used crack cocaine or heroin16

times more likely to have been incarcerated in their life20

ACEs Life Cycle - Children having Children

1

1.5

2

2.5

3

3.5

4

4.5A

dju

sted

Odds

Rati

o

Started Sex Under 16 years (Males)

4+ ACES vs. 0 ACEsGot a girl pregnant when under 18 years

10 x

4+ ACES vs. 0 ACEsFirst child born under 18 years

4x

4+ ACES vs. 0 ACEsMother ≤18 years when born

5x

0

0.5

1

0 1 2-3 4+

ACE Count

18-29 year olds

With no ACEs 3%had hit someone inthe last 12 month

(n=7414, England and Wales, In Prep, Not for Circulation)

With 4 or moreACEs 30% had hitsomeone in the last12 month

Preventing ACES in Wales could reduce

Bellis et al. 2015, n=2028

in adults aged 18-69 years

Prevalence of low mental well-being in adults by the numberof ACEs suffered in childhood

Wales: Length of Healthy LifeIndividuals Diagnosed with a Major Disease by Age (%)

50

60

70

80

90

Cum

ula

tive

%D

eve

loped

Dis

ease

(+/-S

E) Differences remain after adjusting

for Deprivation

Major DiseasesCancerStrokeType 2 DiabetesCardio Vascular Disease

0 ACEs 4+ ACEs

0

10

20

30

40

9 19 29 39 49 59 69

Cum

ula

tive

%D

eve

loped

Dis

ease

Age (years)

41%

21%

Adverse Childhood Experiences and their association with chronic disease and health service use in the Welsh adult population; 2016

10 years10 years

10 years10 years

Cardio Vascular DiseaseDigestive/Liver DiseaseRespiratory Disease

ACE Count

30

40

50

60C

um

ula

tive

%D

eve

loped

Dis

ease

(+/-S

E)

0 4+

Diabetes Type 2 4 or more vs.No ACEs

0

10

20

30

9 19 29 39 49 59 69

Cum

ula

tive

%D

eve

loped

Dis

ease

Age (years)

17.2

12.0

14.0

16.0

18.0

20.0

A&

EA

tte

nd

ance

%Attended A&E

in Last 12 Months

4 or more vs.No ACEs

6.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

0 ACE 1 ACE 2-3 ACEs 4+ ACEs

A&

EA

tte

nd

ance

%

ACE Count**Visited a GP six or more times over the past 12 months

“Support families and parents toreduce adverse childhood experienceswhich can have lifelong effects.“

Supporting Parents – Preventing ACEs

Nurse HomeVisiting

ParentingProgrammes

Child maltreatment

Child injury

High School completion

Sethi et al, 2013

Programmes

PreschoolEnrichment

Violent offences

Employment in mid 20s

First 1000 Days -

Building Resilience - Helping people cope with ACESAvoid damaging behavioural and physiological changes in response to chronic stress

One or more stable, caringchild-adult relationship

Feel you can overcomehardship and guide your

destiny

Grounded in culturaltraditions ‘Connected’

Equipped to manage yourbehaviour and emotions

Based on Strengthening the Foundations of Resilience, Harvard, 2015; Wales ACE Survey, 2015, n=2028, unpublished data

0

5

10

15

20

25

30

35

40

45

Problem Drinkers Used Cocaine or Heroin Been Incarcerated

Perc

enta

ge

Outcome

Never Always

As a child, there was adult you trusted and could talk to about yourproblems?

Children suffering 4+ ACES

Bellis 2016

Safe Environmentfor Every Kid

• Parental depression• Substance abuse

lowers rates of child abuse and neglect and harsh parenting

Screening and Intervention by Primary care professionals

• Substance abuse• Major stress• Intimate partner violence• Food insecurity• Discipline challenges

You need to feel good about yourself to be a good parent.

Trauma InformedPractice

• Workforce Development

• Trauma Screening

• Practice Change

• Inter-Agency Working

• Pre-examinationcompleted ACE survey

• At examinationasked, How haveACEs affected you inlater life?

Tackling hidden reasons for accessing Health Care

• Inter-Agency Working

Machtinger et al. 2015, Lang et al. 2015, Sethi et al, 2010

ACEs affected you inlater life?

• Preliminary Results

– General Practice35%; EmergencyDepartment 11%

The Long Reach of Childhood Trauma, Arielle Levin Becke, 2015

ACEs in Challenging High SchoolsExample from Washington State Family Policy Council

• ACEs

– 1/3 of class had 4+ ACEs

– Best predictor of health,attendance, behaviour

– Educational successrelated more to ACEs

EnquiryWhy

AttachmentCare-giver

relationships

Self-RegulationControl/Share emotional

experience

CompetencyResiliency and

developmental skills

related more to ACEsthan income

• Change

– Public Health and othersinform staff aboutimpacts of ACEs

/www.resiliencetrumpsaces.org; communityresiliencecookbook.org/tastes-of-success/

experience

Graduation rates

ACEs and the Police

• 9 in 10 police contactscomplex welfare, safety &vulnerability

Police and Public Health WalesPolice and Public Health WalesMemorandum of Understanding

…Ensure that from the earliest possible ageindividuals are supported to follow a health

benefiting and crime free life course…

• Develop an ACE informed responsewith Police

ACE Prevention,Response & Resilience“I make a difference”

ACE InformedCommunities

“We work together”

Wales ACE Hub

Individual&

Education CriminalJustice

Government

ACE Awareness“I know ACEs are

important”

ACE Knowledge“I know what I can do”

ACE Skills“I know how to do it”

Individual&

CommunityHealth &

Health care

Justice

Employers

Social Care

Third Sector

With thanks to Kath Ashton, Alisha Davies, Karen

Professor Mark A. BellisDirector of Policy, Research and International Development

Public Health WalesEmail mark.bellis@wales.nhs.uk

With thanks to Kath Ashton, Alisha Davies, KarenHughes, Janine Roderick, Katie Hardcastle, Claudine

Anderson, Andrew Bennett, Tracy Black, KellyEdwards, Ian Molyneux and many, many others.