Adverse childhood experiences

What we know, what we don’t know, and what should happen next

February 1, 2020

Adverse childhood experiences: What we know, what we don’t know, and what should happen next

Summary

This report surveys the evidence relating to the prevalence, impact and treatment of adverse childhood experiences (ACEs), the extent to which ACEs should provide the basis for frontline practice and service design, and the known level of effectiveness and value of ACE-related approaches, such as routine enquiry and trauma-informed care.

Research into ACEs consistently shows that a set of 10 adverse experiences in childhood are associated with an increased risk of poor health and other problems in later life. This evidence has brought greater focus on the harm caused by child abuse, neglect and other adversities.

However, this narrative has increasingly dominated the debate about the role of public services in preventing and responding to childhood experiences of trauma, and has resulted in several misconceptions.

Aims

This report sets out to examine the ACEs evidence base, in terms of its quality and the conclusions which have followed, and to consider the strength of evidence underpinning common responses to ACEs, including routine ACE screening and trauma-informed care.

Key questions:

What do we know about the 10 original ACE categories in terms of their prevalence and co-occurring risks?
How robust are the methodologies used to investigate ACEs? Are there other methods which may be more appropriate?
How strong is the evidence linking ACEs to negative adult outcomes? To what extent has a causal relationship been established?
What biological and social processes link ACEs to negative adult outcomes? Is knowledge of these processes adequate to inform the design and provision of effective interventions and services?
What do we know about the effectiveness of common responses to ACEs, including routine ACE screening and trauma-informed care? What is the effectiveness of other kinds of interventions and what is their combined potential for preventing and reducing ACEs?

Method

The most recent research was identified using hand-search methods involving indexed journals. These methods included:

A review of the findings from ACE studies, as well as child maltreatment prevalence studies conducted in the UK and US since the mid-1980s
A review of the evaluation evidence considering the feasibility of routine ACE screening and trauma-informed care, and their impact in reducing child trauma and improving family outcomes
Evidence gathered from the Early Intervention Foundation Guidebook about interventions which aim to either prevent ACEs from occurring in the first place or respond to ACE-related trauma
Interviews with representatives from Public Health England, Wales and Scotland, prominent children’s charities, independent health organisations and academics.

Key Findings

This report led us to the following conclusions:

Research into adverse childhood experiences (ACEs) has generated a powerful and accessible narrative which has helpfully increased awareness of the lifetime impact of early adversity on children’s outcomes.
The current popularity of the ACE narrative should not lead us to ignore the limitations in the current evidence base or be allowed to create the illusion that there are quick fixes to prevent adversity or to help people overcome it. It is essential that children’s policy and services respond to the fact that understanding, measuring and assessing need is complex, as is responding effectively to complex social problems. We urge caution on the ACE agenda given that:

Current estimates of the prevalence of ACEs are imprecise. Although we know that childhood adversities and vulnerabilities are prevalent, we do not know how prevalent.
Good data on the prevalence of childhood adversity and wider risk factors is lacking. More accurate estimates are essential for understanding the scale of childhood adversity, in order to plan services and to ensure that effective interventions are available for the children and families who most need them.
A focus on the original 10 ACEs to the exclusion of other factors risks missing people who also need help. Many other negative circumstances in childhood are also associated with poor adult outcomes.
ACEs do not occur in isolation. While ACEs occur across society, they are far more prevalent among those who are poor, isolated or living in deprived circumstances. These social inequalities not only increase the likelihood of ACEs, but also amplify their negative impact. This means that structural inequalities must be addressed for ACE-related policies, services and interventions to have any meaningful effect.
The evidence raises serious concerns about the ethics of some ACE screening practices.
Trauma-informed care has the potential to improve the quality of practice, but caution should be used in considering it to be a sufficient response to the complex problems of childhood adversity. Trauma-informed care is not well defined, current practice is highly varied, and there is limited robust UK evidence which demonstrates that it improves outcomes for children. Further specification and testing are needed to fully understand its benefits for children who have experienced adversity.

The current enthusiasm for tackling ACEs should be channelled into creating comprehensive public health approaches in local communities, built on the evidence of what works to improve outcomes for children.

Related Publications

Parenting interventions for parents and carers of disabled children and young people

Learn More

Happier, Healthier Professionals

Learn More

Adverse childhood experiences