Opinion

Adverse childhood experiences

04 July 2017

Professor Mark Bellis is a director of Public Health Wales, an advisor to WHO, and an expert in violence prevention, alcohol, drugs and sexual health. Mark’s talk at the upcoming Unite-CPHVA conference focuses on adverse childhood experiences and their impact on individuals.

Adverse childhood experiences

I’m a public health person,’ says Professor Mark Bellis, speaking from his office in Cardiff. ‘As such, I want people to understand the huge impact that adverse childhood experiences (ACEs) have on individuals and society, wherever you are in the world.’

The director of policy, research and international development for Public Health Wales (one of his many hats) has in recent years led major studies into ACEs. These are stressful events children may face, such as being a victim of neglect and child abuse – physical, sexual or emotional – or exposure to negative behaviours, such as being around adults with alcohol and drug-use problems, mental health conditions, domestic violence or crime.

‘Evidence from our studies show a strong, cumulative association between exposure to adversity in childhood and the adoption of health-harming behaviours and poor mental health across the life course,’ he says.

Mark led the first national ACE studies in England in 2013 and then in Wales in 2015. These found that almost half the general population reported at least one ACE and around 10% reported four or more.

The studies have been retrospective and based on face-to-face interviews with more than 4000 adults (in the English study) and 2000 (in the Welsh), who provided anonymous information on their exposure to ACEs before the age of 18, and their health and lifestyles as adults.

One major goal was to ascertain the association between ACEs and chronic disease and health-service use. Across England and Wales the percentage who experienced childhood exposure to verbal abuse was 18% and 23%; parental separation, 24% and 20%; physical abuse, 15% and 17%; and domestic violence, 13% and 16%. Exposure to other ACEs were mental illness (12%; 14%); alcohol abuse (10%; 14%); and sexual abuse (6%; 10%).

The researchers focused on those with four or more ACEs (compared to those who had none) in relation to their increased risk of developing health-harming behaviours – such as being a high-risk drinker (twice as likely in England, four times as likely in Wales); involved in violence (seven and 
15 times more likely); and using crack cocaine or heroin (11 times and 16 times more likely). This group was twice as likely to develop a chronic disease, such as type 2 diabetes, heart and respiratory disease, and cancer, as those with no ACEs.

‘In those without ACEs, 20% have developed one of these serious conditions by the age of 59,’ says Mark. ‘Among those with four or more, it’s twice that figure, 40%.’

Not surprisingly, levels of health-service use were higher in the ACE-heavy groups. During the past year, they were twice as likely to have frequently visited a GP, and three times more likely to have attended A&E or stayed overnight in hospital.

‘We understand these issues don’t just have a dramatic influence on the direct experiences of a child,’ says Mark. ‘People exposed to ACEs are more likely to grow up to become smokers, drinkers, get pregnant underage, or take drugs – to be “troubled”,’ he says.

Prolonged exposure to childhood stressors can result in children becoming ‘locked’ into a higher state of alert to threat. ‘And in that state of alert, bodies wear out more quickly. They are physiologically adapted to short-term survival as they become permanently prepared to respond to further trauma.’

Such adaptation – never ‘switching off’ – also increases tissue inflammation, which we know is a trigger for many diseases.

‘ACEs in childhood can also compromise how individuals learn to regulate their emotions, control their impulses or manage their behaviour. Reduced self-control and difficulty with interacting socially increase their need for coping mechanisms – drinking, smoking and drug use.

‘One way that ACEs spread is from one generation to the next. People exposed to ACEs such as violence are more likely to grow up to be violent themselves,’ says Mark.

However, the picture’s not all bleak, he asserts. ‘There’s a strong argument for informed assessment by trained professionals to ask about ACEs, identify those at risk and intervene where children may already be victims of abuse, neglect or living in adverse childhood environments.

‘It’s important to better equip parents and caregivers with the skills to avoid ACEs arising in the home, and encourage social and emotional wellbeing as well as resilience in the child – to ensure indirect harms from domestic abuse at home are identified and addressed, and the impact on children minimised.’


All about Mark

  • Born in the town of Heswall, on the Wirral
  • One of the directors of Public Health Wales, and works from bases in Wrexham and Cardiff
  • After living in northern England, moved back to Heswall
  • Married and has three children
  • Part of the expert advisory group responsible for the new guidelines for alcohol consumption set up in 2016
  • Has published more than 160 academic papers, including Dying to be famous, on rock stars and ACEs.

He refers to a school in Walla Walla in Washington State, where staff are trained to be aware of ACEs and their impact on the children. ‘By asking “What’s wrong?” instead of saying “You can’t behave like that”, they’ve seen a reduction in school exclusions and violence – and better educational results.’

Mark’s team is currently developing a national ACE hub to raise awareness of the issue, and are looking at how health systems can respond. ‘Prevention is key – and building a safer environment for every kid.

‘And you have to remember, not all children exposed to ACEs will go on to have mental and physical health issues.’ He refers to a study that shows how, for a child, having just one trusted adult around can make a difference to that individual’s health across their life course. ‘With a trusted adult around, the child can relax, and avoid the long-term toxic stress that causes so much damage.

‘Children’s resilience can come from parents, teachers, sports coaches… Relatively small interventions can help a child, and the benefits can be seen through the decades. Professionals working with young families who have an understanding of where trauma has been in the family can do a lot to provide support and put preventive measures in place.

‘And we can see how later on, say in a person’s teens, the frustrations and problems that might have arisen from ACEs have been channelled into good outcomes, such as taking up a dedicated approach to excellence in sport.

‘Do we mend broken adults, with all the costs to society that implies, or avoid those problems by building strong, happy children?’ he asks. ‘The choice is simple, really.’

The Unite-CPHVA Annual Professional Conference 2017 will be held in Cardiff on 17-18 October. Early bird tickets are available until 7 August. For information, visit cphvaconference.co.uk

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