Dr Aideen Naughton Service Lead Safeguarding Children Service Public Health Wales

1. Wales Adverse Childhood Experiences (ACE) Study Dr Aideen Naughton Service Lead Safeguarding Children Service Public Health Wales Insert name of presentation on Master Slide--

2. Early Intervention Foundation 2015 Spending on late intervention :how we can do better for less

3. WHO European Report on preventing child maltreatment 2013 • Leads to premature death at least 850 children pa under 15yrs • Sexual abuse(18 million)physical abuse (44 million) emotional abuse(55 million) • Rates of homicides in low and middle income countries more than x 2 high income countries • PTSD in 1 in 4 abused children • Accounts for almost 25% mental disorders • Emerging evidence suggests economic and social costs run into 10s of billions of Euros

4. WHO European Prevention Action Plan Goal: To reduce the prevalence of child maltreatment by implementing programmes that address risk and protective factors, including social determinants Target: Reduce the prevalence of child maltreatment and child homicide rates by 20% by 2020 Investing in children: the European child maltreatment prevention action plan 2015-2020

5. WHO European Prevention Action Plan • Strengthen data collection to show and monitor the extent of the problem • Develop comprehensive national action plans for violence prevention • Integrate violence prevention into other health platforms • Implement evidence informed programmes • Upgrade the quality of services for victims Investing in children: the European child maltreatment prevention action plan 2015-2020

6. WHO European Prevention Action Plan 6. Improve the enforcement and quality of existing laws 7. Build health systems capacity for violence prevention 8. Focus on equity and the life course Investing in children: the European child maltreatment prevention action plan 2015-2020

7. Survivors of childhood abuse and neglect often suffer from health problems long after the abuse has ended Higher rates of healthcare use Higher healthcare costs More reported symptoms More chronic pain syndromes Overall less satisfaction with their health Legacy for Adult Health

8. It can be contagious.............

9. Consequences for Adulthood • The Adverse Childhood Experiences (ACE)- US • 50+ Publications • ACE score : increased rates • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease • Depression • Health-related quality of life • Ischemic heart disease • Liver disease

10. What are ACEs? ACEs are stressful experiences occurring during childhood that directly harm a child (e.g. sexual or physical abuse) or affect the environment in which they live (e.g. growing up in a house with domestic violence). ACEs and their association with health-harming behaviours in the Welsh adult population

11. What are ACEs? Verbal abuse Physical abuse Sexual abuse Incarceration Domestic violence Mental illness Alcohol abuse Drug abuse Parental separation ACEs and their association with health-harming behaviours in the Welsh adult population

12. The Brain and Maltreatment The most sensitive and responsive organ to the Environment • Impact of stress • Impact of deprivation • Timing of insult • Duration of trauma

13. Brain Development - The Critical Years • First 2 years - baby’s brain grows from 25% to 80% of adult size • Development continues in childhood learning empathy, trust and community

14. The Impact of ACEs on Brain Development Chronic Stress from ACEs over-develop ‘life-preserving’ part of the brain. Fight or Flight Healthy response Fixed Allostatic load Exhausted Recovery Threat ACEs At Rest At Rest Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014

15. Brain Development - The Critical Years • First 2 years - baby’s brain grows from 25% to 80% of adult size • Development continues in childhood learning empathy, trust and community

16. Anxious Always prepared to fight or flee Disengaged Poor learner

17. Impact of Early Maltreatmenton the Neurological System Maltreatment and trauma in early years results in: • Overdevelopment of neurophysiology of brainstem and midbrain (anxiety; impulsivity; poor affect regulation; hyperactivity); • Deficits in cortical (problem-solving) and limbic function (empathy)

18. Adverse Childhood Experiences ACEs - The Life Course Developed from Felitti et al. 1998 DEATH Early Death LIFE COURSE Non Communicable Disease, Disability, Social Problems, Low Productivity Adopt Health Harming Behaviours and Crime Social, Emotional and Learning Problems Disrupted Nervous, Hormonal and Immune Development ACEs Adverse Childhood Experiences BIRTH

19. Felitti V.J. 1998

20. Felitti V.J. 1998

21. Felitti V.J. 1998

22. Need to understand the prevalence of ACEs in Wales to be able to focus efforts on prevention Insert name of presentation on Master Slide

23. Professor Mark Bellis, Director of Policy, Research and International Development Public Health Wales NHS Trust

24. Welsh ACE survey 2015 - Methods • National cross-sectional survey using quota sampling • Face-to-face interviews with approximately 2,000 Welsh residents aged 18-69 years • Of those eligible to participate, just under half agreed to take part • Questions about their current health behaviours and their exposure to ACEs using an internationally validated ACE questionnaire. • A respondent’s ACE score is based on a count of the number of different types of adverse events they experienced (range 0 to 9). This does not account for reoccurring events or the duration of events. ACEs and their association with health-harming behaviours in the Welsh adult population

25. Results – Overall prevalence of ACEs For every 100 adults in Wales, 47 have suffered at least one ACE during their childhood and 14 have suffered 4 or more. In comparison to England, Wales has a higher proportion of adults who have experienced 4 or more ACEs. Overall, 14% of the Welsh adult population are estimated to have experienced 4 or more ACEs, compared to 9% in England. ACEs and their association with health-harming behaviours in the Welsh adult population

28. ACEs increase individuals’ risk of developing health harming behaviour

30. Breaking the ACE cycle in Wales Focus on resilienceto build the protection factors which guard individuals within times of adversity How? • Identify and intervene where children may already be victims of CAN or living in adverse environments • Better equip parents and care givers with the necessary skills to avoid ACEs within the home and to promote development of social emotional well being and resilience in the child • Ensure that domestic abuse, substance use and other mental and behavioral problems in the family setting are identified, addressed to minimise the impact on children ACEs and their association with health-harming behaviours in the Welsh adult population

31. Welsh Policies • Wales is pioneering a range of policies and programmes: • Building a Brighter Future: Early Years and Childcare Plan 2013-2023 • The Healthy Child Wales Programme • Promotion behaviours to support positive parent child relationships resulting in secure emotional attachment • Promotion of positive maternal and family emotional health and resilience • Tackling Poverty programmes such as Flying Start and Families first ACEs and their association with health-harming behaviours in the Welsh adult population

32. Breaking the ACE cycle in Wales • United in Improving Health – co-production and coordination of assets, investment and activity in Wales to accomplish a shared set of goals • E.g improving outcomes in the early years with a focus on the first two years of life • Well-being of Future Generations (Wales) Act 2015 • 7 goals including a resilient Wales, a healthier Wales, a more equal Wales ACEs and their association with health-harming behaviours in the Welsh adult population

33. Next steps.. • Further results will be published later this year • Future reports will cover the impact of ACEs on chronic ill health, use of health and social care services, premature mortality and mental well-being in Welsh adults. ACEs and their association with health-harming behaviours in the Welsh adult population

34. Useful references • Felitti VJ, Anda RF, Nordenberg 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 Preventive Medicine 14:245–258. • Anda RF, Felitti VJ and Bremner JD. 2006. ‘The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology’European Archives of Psychiatry and Clinical Neuroscience 256(3):174-186. • Bellis MA, Hughes K, Leckenby N, Perkins C and Lowey H. 2014a. ‘National Household Survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England’. BMC Medicine 12:72. • Bellis M, Hughes K, Leckenby N, et al. 2014b. ‘Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in the European region’. Bulletin of the World Health Organisation 92(9):621-696. • Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. 2004. ‘The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial outcomes, and fetal death.’Pediatrics 113(2):320–327. ACEs and their association with health-harming behaviours in the Welsh adult population