Measuring their impact on long-term health and the wider economy

Counting the Cost of Adverse Childhood

Experiences

Professor Mark A. BellisDirector of Policy and International Health

World Health Organization Collaborating Centre on Investment for Health and Well-being, Public Health Wales, United Kingdom

Email: m.a.bellis@bangor.ac.uk; Twitter @markabellis

How many people have suffered ACEs?

Bull World Health Organ 2014;92:641–655B; Bellis et al, 2014, 2016, 2018; Merrick et al, 2018

Physical abuse

18%average

AlbaniaNorth Macedonia7%41%

Romania

Turkey

Russian Federation

MontenegroSerbia

Ukraine15%19%

Moldova

16%Latvia

13%Lithuania

Poland

Czech Republic

20%18%

23%18%

11%

13%

15%

England

15%

6%

18%

24%

12%

12%

10%

4%

4%

ACEs measured

Physical abuse

Sexual abuse

Emotional abuse

Parental separation

Domestic violence

Household member:

Mental illness

Alcohol problem

Drug user

Incarcerated

Euro

18%

6%

10%

16%

13%

11%

16%

3%

5%

Wales

16%

7%

17%

25%

17%

18%

13%

6%

4%

USA

18%

12%

34%

28%

18%

17%

28%

8%

Eastern Europe 49% suffered at least one ACE, 6% 4+ ACEsEngland 48% suffered at least one ACE, 9% 4+ ACEsWales 50% suffered at least one ACE, 14% 4+ ACEsUSA 62% suffered at least one ACE, 16% 4+ ACEs

Child Maltreatment and other Adverse Childhood Experiences ACEs - The Life Course

Early Death

Social, Emotional and Learning Problems

Adopt Health Harming Behaviours and Crime

Disrupted Nervous, Hormonal and Immune Development

Child Maltreatment & other Adverse Childhood Experiences (ACEs)

Non Communicable Disease, Disability, Social Problems, Low Productivity

Life

Cou

rse

Death

Birth

Developed from Felitti et al. 1998Bellis 2016

£

WEIGHT & EXERCISE

1.4Physical inactivity

Obesity

1.22.1 1.5

PHYSICAL HEALTH

DiabetesHeart diseasePoor self-rated health

Cancer

Liver/digestive disease

Respiratory disease

2.2

2.3

2.8

3.0

3.7

MENTAL HEALTH

4.4

4.4

Anxiety

Low life satisfaction

Depression

Collaborative Global ACE Analysis with WHOSEXUAL HEALTH

3.6

3.7

4.2

5.9

Multiple sexual partners

Early sexual initiation

Teenage pregnancy

STIs

10.2

SUBSTANCE USE

2.22.8

5.6

5.8

SmokingHeavy alcohol use

Illicit drug use

Problem alcohol use

Problem drug use

7.58.1 30.1

VIOLENCE

Suicide attempt

Violenceperpetration

Victimisation

Hughes, Bellis, Hardcastle et al, 2017 Lancet Public Health

4+ACEsVs

No ACEs

Objectives•Aim• Create a life course measure of the main health-related costs of ACEs

Estimate Prevalence of ACEs

Calculate the proportion of common health conditions caused by ACEs

Convert health into Disability Adjusted Life Years

Convert DALYs to financial costs (Gross Domestic Product per person per Year)

(Bellis et al 2019; Lancet Public Health)

ACEsDALYS €Human

Capital Model

Population Attributable

Fraction

articles using unique samples on health topics included in Euro and NA

Full text obtained for 880 articles

4,387 unique references subjected to title/abstract review

9,156 references retrieved in searches

221 articles considered for inclusion

Study Selection

23(Bellis et al 2019; Lancet Public Health)

23.5% 1 ACE18.7% 2+ACEs

319 million individuals 15+ years with

1+ACE

23.4% 1 ACE35.0% 2+ACEs

172 million individuals 15+ years with at least 1 ACE

(Bellis et al 2019; Lancet Public Health)

ACEs

Increased risk of ill health outcomes by ACE Count

• Risks consistently higher as ACE counts increases• Similar increases

between continents• Smoking Euro NA• 1 ACE 29%↑ 23%↑• 2+ ACEs 82% ↑ 74%↑

• Some differences in risk • Cancer Euro NA• 1 ACE 8%↑ 10%↑• 2+ ACEs 58%↑ 25%↑

Population Attributable

Fraction

• Risk Factors• Harmful Alcohol Use• Illicit Drug Use• Smoking• Obesity

• Causes of Ill health• Anxiety• Depression• Cancer• Cardiovascular Disease• Diabetes• Respiratory Disease

DALYSDisability Adjusted Life YearsW

este

rn E

urop

e, B

oth

Sexe

s, A

ll A

ges,

201

7

Institute for Health metrics

Expected life years

RIP

Early Death

HUMAN CAPITAL MODEL- assign a monetary value to loss of health calculated as reduced or lost economic productivity.

25% 34%18% 6%

28% 28%11% 12% 8% 19%

alcohol

illicit drug use

smoking

obesity

Anxiety

Depression

Cancer

Cardiovascular dis.

Diabetes

Respiratory dis.

$BillionsPer year

Fraction attributable to

ACEs

The Costs of ACEs across Europe

$143

$46

$165 $

40

$23

$29

$117

$185

$16

$47

Bellis, Hughes, Ford, Rodriguez, Sethi, Passmore, 2019 €Human

Capital Model

MINIMUM COST to Europe per Year $581 BILLON and combined with NORTH AMERICA $1.3 Trillion

HUMAN CAPITAL MODEL- assign a monetary value to loss of health calculated as reduced or lost economic productivity.

25% 34%18% 6%

28% 28%11% 12% 8% 19%

alcohol

illicit drug use

smoking

obesity

Anxiety

Depression

Cancer

Cardiovascular dis.

Diabetes

Respiratory dis.

$BillionsPer year

Fraction attributable to

ACEs

The Costs of ACEs across Europe

$143

$46

$165 $

40

$23

$29

$117

$185

$16

$47

Bellis, Hughes, Ford, Rodriguez, Sethi, Passmore, 2019 €Human

Capital Model

MINIMUM COST to Europe per Year $581 BILLON and combined with NORTH AMERICA $1.3 Trillion

• 2+ACEs account for around 3/4 of costs• Costs fall on • Whole population ($1,000 person per year– Euro & NA)• Health, Education, Crime, Social sectors

•Maltreatment, other ACEs and their Cost are preventable• INSPIRE and other cost-effective model

•At a Country level possible to• Measure more accurately how major health conditions and

care costs are related ACEs• Other costs (criminal) related to ACEs• Potential savings from investing in prevention of child

maltreatment and other adversity

OUTCOMES

Population Attributable Fractions England

10%

25%64%

Wales

0% 10% 20% 30% 40% 50% 60%

Alcohol use

Drug abuse

High BMI

Violence

Anxiety

Cancer

Heart Disease

Type 2 Diabetes

1 ACE 2-3 ACEs 4+ ACEs

Northern Ireland Gross Domestic Product –

2017 (2018 prices) - £26,014 per capita

Nor

ther

n Ir

elan

d,

Both

Sex

es, A

ll A

ges,

20

17

Annual Costs of ACEs in Northern Ireland

High BMI

22 million

Alcohol use

87 million

Drug use

129 million

Smoking

217 million

HEALTH RISKS

77 million

Depression

CAUSES OF ILL HEALTH

Violence

13 million

Type 2 diabetes

41 million

Anxiety

88 million

Other mental illness

209 million

Cancer

229 million

148 million

Respiratory disease

Heart disease

134 million

101 million

Stroke

Combined cost(excluding duplication)

£1.3 billion Per annum

Professor Mark A. BellisDirector of Policy & International Health, World Health Organization

Collaborating Centre on Investment for Health and Well-beingEmail - m.a.bellis@bangor.ac.uk, Twitter - @markabellis

Bellis, Hughes, Ford, Rodriguez, Sethi, Passmore; www.thelancet.com/public-

health Vol 4 October 2019

WHO Collaborating Centre