Adverse Childhood Experiences (ACEs) – resources for practitioners

Everyone goes through stress as a child – failing at something we cared about, having to move house or change school, or losing a friend or pet. These experiences help us grow and become resilient.

But adverse childhood experiences are not something a child can just bounce back from. They are too overwhelming and scary, or they are situations that see a child lacking any real support.

Adverse Childhood Experiences (ACE) refer to some of the most intensive and frequently occurring sources of stress that children may suffer early in life.

When children are exposed to adverse and stressful experiences, it can have a long-lasting impact on their ability to think, interact with others and on their learning.

It has been shown that considerable and prolonged stress in childhood has life-long consequences for a person’s health and well-being, with negative behaviours often being used unconsciously as protective solutions to unrecognised problems dating back to childhood.

Work across the country aims to both prevent ACEs occurring in the first place wherever possible, and to prevent the consequences of ACEs in those that have already experienced them.

ACEs can be prevented – research has found that a relationship with one trusted adult during childhood can mitigate the impacts of ACEs on mental and physical well-being.

Our Manchester Approach

Manchester residents have poorer health outcomes and a lower life expectancy than people living in other areas of the country. We have one of the highest rates of premature deaths in the country and high infant mortality rates.

Health services alone cannot improve people’s health and reduce health inequality. We owe it to our residents to change the way we work and do something differently to improve their health and reduce inequality across all age groups.

What Can We Do?

  • Look ‘behind the behaviours’ and consider what the root cause of the presenting behaviour may be.
  • Use protective factors to build resilience e.g. secure attachment, opportunities for positive activities and supportive networks.
  • Adopt a trauma-informed approach with a focus on ‘what happened to you?’ instead of ‘what’s wrong with you?’
  • Consider how to apply the core principles of trauma-informed practice: Safety – Choice – Collaboration – Empowerment – Trust. 

What Are We Doing?
Following a successful pilot project in Harpurhey we are rolling out ACE awareness training and developing trauma informed approaches across Manchester. We have published our ACEs Trauma Informed Strategy 2019/25 to outline our plans.

Our ambition is to work towards Manchester becoming a trauma informed city by 2025. A city where we can break the generational cycle by preventing ACEs in our young people and strengthen resilience in individuals, families and communities leading to better life outcomes.

Further Information
To get involved in this movement please contact:

Manchester initiatives 

Manchester City Council and Rock Pool are working together on a place-based pilot to help staff from public, voluntary and community sector services, better understand Adverse Childhood Experiences.

The project aims to determine if a deeper level of engagement and understanding of the root causes of behaviours, rather than ‘treating’ presenting behaviours can make the current local intervention offer work more effectively.

The project is undergoing constant evaluation and will test whether having a trauma-informed workforce at place level (not particular organisations) allows the workforce to engage on a deeper level with service users/people with lived experience.

The organisations involved in this new, integrated model of workforce reform include Integrated Neighbourhood Teams, police & Fire and Rescue,  Youth Services, Voluntary and Community Sector, health services, health visiting & GPs, Social & Early Help services, substance misuse services, Mental Health services, Domestic Violence and Abuse services, Early Years & nurseries, schools (primary and secondary) and a college.

The project emphasises the Our Manchester approach of recognising strengths of individuals and community, of working together and improving lives.

Once the training has been completed and is informing practice, Rock Pool will work with Manchester City Council to develop a cohort of Train the Trainers. Their role will be to act as advocates in their organisation and sector, and deliver the training on a wider scale.

What is an Adverse Childhood Experience (ACE)? 

The term ACE is used to describe a wide range of stressful or traumatic experiences that children can be exposed to whilst growing up. ACEs range from experiences that directly harm a child (such as suffering physical, verbal or sexual abuse, and physical or emotional neglect) to those that affect the environment in which a child grows up (including parental separation, domestic violence, mental illness, alcohol abuse, drug use or incarceration).

The Commons Select Committee report: Evidence-based early years intervention published in November 2018  cited that whilst there is no universally agreed definition of an adverse childhood experience (ACE) studies addressing the issue have mostly converged on a similar set of experiences falling under this term and listed the following experiences:

  • verbal abuse
  • physical abuse
  • sexual abuse
  • physical neglect
  • emotional neglect
  • parental separation
  • household mental illness
  • household domestic violence
  • household alcohol abuse
  • household drug abuse
  • incarceration of a household member.

Prevalence of ACEs

It is more common to have a few or several ACEs rather than just one. Over 12% of participants in the original US study scored four or higher.

UK studies showed:

  • Wales – almost 50% experienced 1 ACE and 14% experienced 4 or more
  • England – almost 50% experienced 1 ACE and over 8% 4 or more
  • Scotland does not have an ACE survey but it is proposed a similar prevalence of ACEs can be assumed.

The evidence for the Commons Select Committee report cited:

  • 50% of Welsh adults had experienced at least one ACE
  • 47% of English adults had experienced at least one ACE
  • Scottish Public Health estimated that prevalence in Scotland would be at least as high.

The Children’s Commissioner’s Office estimated at least 690,000 children aged 0–5 in England live in a household with an adult that experienced domestic violence and abuse, substance misuse or mental health issues.

ACEs and health inequalities

The North West Population Health & Prevention Network has reported considerable work going on across the world from WHO to Public Health Wales and pockets in England.

A UK study suggests those with 4+ACEs are:

  • 2x more likely to have a poor diet
  • 2x more likely to binge drink
  • 3x more likely to smoke
  • 5x more likely to have had sex under 16 years
  • 6x more likely to have been pregnant or got someone accidentally pregnant under 18
  • 7x more likely to be involved in recent violence
  • 11x more likely to have been incarcerated
  • 11x more likely to have used heroin or crack.

Read a summary and review of national and international ACE activity on the research website at www.nwcpwd.nhs.uk/Adverse_Childhood_Experiences.pdf

Can ACEs be prevented? 

ACEs are a primary example of the complex issues the multi-agency safeguarding workforce often faces. The negative effects of ACEs are felt throughout the community and can affect people of all backgrounds.

Early intervention and collaborative working are essential to reducing the impact of ACEs. Early intervention refers to taking action to resolve problems as soon as possible, before they become more difficult to reverse.

The Select Committee report of November 2018 recommended early intervention in relation to childhood adversity and trauma, to tackle the potential long-term problems that those who encounter such experiences are more likely to encounter; and a new adversity-targeted early intervention strategy.

Stable, nurturing adult-child relationships and environments help children develop strong cognitive and emotional skills and the resilience required to flourish as adults. By encouraging such relationships ACEs can be prevented, even in difficult circumstances, and it is crucial to support and nurture children and young people as they develop and grow.

For adults who experienced ACEs in their childhood, it is possible to minimise the impact of ACEs on their health, relationships and lives in general.

Tackling ACEs

Preventing ACEs should be seen within the wider context of tackling societal inequalities. While ACEs are found across the population, there is more risk of experiencing ACEs in areas of higher deprivation.

ACEs have been found to have lifelong impacts on health and behaviour and they are relevant to all sectors and involve all communities. Everyone has a part to play in preventing adversity and raising awareness of ACEs. Resilient communities have an important role in action on ACEs.

Approaches and initiatives that can be developed include:

  • raising awareness of ACEs
  • reporting and recording ACEs into specific public health contracts (eg for sexual health and substance misuse)
  • bringing ACEs into Early Action Programmes
  • train staff to be able to routinely enquire about ACEs
  • support local schools to be ACE-Aware and ACE-informed
  • support social movements around ACEs.

Offering support

Although the effects of ACEs can last a lifetime, they don’t have to. By getting support, young people and adults can both reduce the impact of ACEs on their own life and break the cycle to prevent ACEs occurring in the next generation.

This support can come from something as simple as a chat with a friend or family member, from a GP, or through one of the local and national organisations that can help recognise, work through and reverse the impact of ACEs.

Help & Support Manchester provides a directory of information about services, opportunities, advice and guidance to help individuals and families improve their lives – find these at hsm.manchester.gov.uk

Resources are listed below for both practitioners and the public. Further signposting to support on a range of issues or concerns can be found in our resource hub.

Online Resources 

E-learning
A Manchester e-learning package is in development.

PowerPoint
The presentation ‘Adverse Childhood Experiences – Public Health Masterclass’ given by Jacqui Reid-Blackwood, Public Health Programme Manager for Public Health England can be downloaded from www.nwcpwd.nhs.uk/Presentation.pdf.

Awareness Raising animations and films
Public Health Wales and Blackburn with Darwen have produced a short-animated film to raise awareness of ACEs, their potential to damage health across the life course and the roles that different agencies can play in preventing ACEs and supporting those affected by them.

The ACE animation tells the story of a young boy growing up, and how his experience with ACEs could affect his life experience:

NHS Health Scotland have produced a short animation to raise awareness about the impact of childhood adversity and stimulate discussion about what action can be taken to both prevent and respond to early adversity.

The RAISE Team worked with young people across the Liverpool CAMHS partnership have captured some real-life views on how ACEs can affect someone’s life, but more importantly, focusing on how accessing support really helped them.

TED talks
Paediatrician Nadine Burke Harris explains that the repeated stress of abuse, neglect and parents struggling with mental health or substance abuse issues has real, tangible effects on the development of the brain.

Produced by the fostering promotion group ReMoved, this TedX features the story of a resilient, fictional young girl called Maja; who, frightened of her own father, is uncertain of when she may reach safety or if she will ever be properly loved and cared for.

Another TEDx discusses the global prevalence of Adverse Childhood Experiences (ACEs) like neglect, abuse and dysfunctional parenting, and how they drive poor public health, low productivity and other costs among adult populations.

Campaign Resources

The 70/30 campaign
The 70/30 campaign is a national campaign led by children’s charity, WAVE Trust which aims to reduce child abuse and neglect by 70% by the year 2030 by increasing local and national demand for primary prevention (preventing child maltreatment from ever occurring) through the efforts of its dedicated Ambassador network.

The Mayor of Greater Manchester has endorsed the 70/30 campaign and the Wave Trust has engaged with the Greater Manchester Local Authority, feeding into their work to become one of the foremost UK local authorities in implementing early intervention.

It aims to empower front-line professionals, organisations, charities and community members through information-sharing, research and a variety of resource materials to make the change towards the prevention of child abuse and neglect that we all want to see for our children.

Their website contains a host of resources including info-graphics, research, blogs and books and a collection of videos that share and explain the 70/30 message.

Beyond Adversity campaign
Addressing Adversity is part of the Young Minds Beyond Adversity campaign calling for better support for children and young people who have experienced trauma and adversity.

Addressing Adversity is a nationwide project that promotes trauma informed practice that helps professionals to support children and young people who have experienced distressing or disturbing times. YoungMinds compiled this collection to raise awareness about the impact of adversity and trauma on the mental health of children and young people; materials include the latest evidence, insight and good practice to support commissioners, providers and practitioners to prioritise adversity and trauma-informed care across England.

The science behind ACEs 

When exposed to stressful situations, the ‘fight, flight or freeze’ response floods the brain with corticotrophin-releasing hormones (CRH), which usually forms part of a normal and protective response that subsides once the stressful situation passes.

However, when repeatedly exposed to ACEs, CRH is continually produced by the brain, which results in a child remaining permanently in this heightened state of alert and unable to return to their natural relaxed and recovered state.

Consequently, children and young people who are exposed to ACEs have increased – and sustained – levels of stress. In this heightened neurological state, a young person is unable to think rationally and it is physiologically impossible for them to learn.

ACEs can have a negative impact on development in childhood which in turn can give rise to harmful behaviours, social issues and health problems in adulthood. There is now a great deal of research demonstrating that ACEs can negatively affect lifelong mental and physical health by disrupting brain and organ development and by damaging the body’s system for defending against diseases. The more ACEs a child experiences, the greater the chance of health and/or social problems in later life.

ACEs research shows that there is a strong correlation between ACEs and poor physical and mental health, chronic disease (such as type II diabetes, chronic obstructive pulmonary disease; heart disease; cancer), increased levels of violence, and lower academic success both in childhood and adulthood.

Further reading and resources

The Commons Select Committee for Sciences and Technology report: Evidence-based early years intervention is a parliamentary committee inquiry into Adverse Childhood Experiences (ACEs) by highlighting a need for better evidence to inform support for adopted children.

The inquiry looked specifically at how research into ACEs can be more effectively mobilised to form better health, education and social policy.

A Crying Shame – a report by the Office of the Children’s Commissioner into vulnerable babies in England (October 2018) claims 16,000 babies are growing up in households where they are at risk of severe harm and that of 19,640 under-ones identified as being ‘in need’, 15,820 were still living at home.

It also estimates that 8,300 babies are growing up amid the ‘toxic trio’ of drug or alcohol addiction, domestic violence and severe mental ill-health.

The Scottish Public Health Network (ScotPHN) report ‘Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland’ provides an overview on ACE and makes a number of recommendations.

Welsh Adverse Childhood Experiences (ACE) Study
Reports relating to Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population can be found on the Public Health Wales website at www.wales.nhs.uk

There are a number of topic based reports and supporting info-graphics:

  • Report: ACEs and their impact on health-harming behaviours (Jan 2016)
  • Info-graphic: ACEs and their impact on health-harming behaviours (Jan 2016)
  • Report: ACES and their association with mental well-being (June 2016)
  • Info-graphic: ACES and their association with mental well-being (June 2016)
  • Report: ACEs and their association with chronic disease & health service use (Nov 2016)
  • Info-graphic: ACEs and their association with chronic disease and health service use (Nov 2016)
  • Report: Sources of resilience and their moderating relationships with harms from adverse childhood experiences (Jan 2018)
  • Info-graphic: Sources of resilience and their moderating relationships with harms from adverse childhood experiences (Jan 2018).

Articles and blogs
The Adverse Childhood Experiences evidence base–a wake-up call to radically redesign Children’s Mental Health Services – read at weneedtotalkaboutchildrensmentalhealth.wordpress.com/2017/10/30/the-adverse-childhood-experiences-evidence-base-a-wake-up-call-to-radically-redesign-childrens-mental-health-services/

Read a useful article about the ACE studies at www.connectedforlife.co.uk/blog/2017/6/17/the-adverse-childhood-experiences-ace-study

The article at www.leedstrinity.ac.uk/blogs/Adverse-Childhood-Experiences-too-High considers ACEs and argues that the concept has a clear relevance and application for practice with children and families going forward.

USA websites
Harvard University article on ACEs and Toxic Stress: Frequently Asked Questions can be read at
developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

Centers for Disease Control and Prevention (CDC) studies and Adverse Childhood Experiences Presentation Graphics can be found at
www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html

Further Centre for Youth Wellness articles can be read at  centerforyouthwellness.org/ace-toxic-stress/

ACE studies

Routine Enquiry About Adversity in Childhood (REACh): pathfinder study 2018
REACh was implemented across a large multi-site general practice in the North West of England to consider the feasibility and acceptability of ACE enquiry in general practice from both the patient and the practitioner perspective, and provides some initial insight into the potential impact of ACE enquiry on service delivery and patient health outcomes.

Routine Enquiry About Adversity in Childhood (REACh): implementation pilot evaluation May 2018
The Department of Health and Social Care asked Lancashire Care Foundation Trust to develop an implementation pack to support services in developing, implementing and embedding routine enquiry about adversity in childhood. The implementation pack was piloted by 3 services in north-west England.

ACE  collaborative study for Northamptonshire, Hertfordshire and Luton

Original US study
ACEs grew out of a large-scale American public health research study, the Adverse Childhood Experiences Study (ACE study). The idea for which was triggered when a doctor running an obesity programme discovered that most of their clients had suffered childhood sexual abuse.

The original ACEs study, conducted in the USA, found that around two thirds (64%) of the 17,000 individuals included in the study reported at least one ACE, with over a quarter (26%) suffering physical abuse and a fifth experiencing some form of sexual abuse. Around one in eight individuals (13%) had experienced four or more ACEs. The study found the direct impact on a number of health issues, such as addiction, mental health, diabetes, violence for those people who had experienced childhood adversity.

Felitti, M. D., Anda, R. F., Nordenberg, M. D. et al (1998) ‘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 Preventative Medicine. 14.

Downloads and supporting graphics available on this page:

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