Centre for Public Health

Liverpool John Moores University

Public Health Institute - Liverpool John Moores University

World Health Organization Collaborating Centre for Violence Prevention

Part of the Liverpool John Moores University

Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences (ACEs)

A growing body of research is revealing the long-term impacts that experiences and events during childhood have on individuals’ life chances. Adverse Childhood Experiences (ACEs) such as abuse, neglect and dysfunctional home environments have been shown to be associated with the development of a wide range of harmful behaviours including smoking, harmful alcohol use, drug use, risky sexual behaviour, violence and crime. They are also linked to diseases such as diabetes, mental illness, cancer and cardiovascular disease, and ultimately to premature mortality.

The relationship between ACEs and the development of health harming behaviours and chronic disease in adulthood was first explored in the USA by Felitti et al 1998. Based on this research, organisations including the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have strongly promoted research into ACEs internationally and have developed standard ACE tools to support measurement of the prevalence and impact of ACEs on population health.

In 2012, the Centre for Public Health ran the first UK study using internationally validated ACE tools in Blackburn with Darwin (BwD; Bellis et al, 2014a). This found that increasing ACEs were strongly associated with adverse behavioural, health and social outcomes across the life course. Subsequently, a national ACE study was undertaken in England in 2013. This found that almost half of the general population reported at least one ACE and over 8% reported four or more (Bellis et al, 2014bc). Researchers within the violence and nightlife team at CPH have recently contributed to a study being conducted by Public Health Wales which is examining the national prevalence of ACEs in Wales. Further, CPH has been commissioned by Hertfordshire, Luton, and Northamptonshire Local Authorities and Public Health England to also examine the impact of childhood experiences on health. The research aims to understand the prevalence of ACEs and their impact on morbidity and mortality in later life in Hertfordshire, Luton, and Northamptonshire. The key objectives of the study are to measure the prevalence of ACEs, the increased odds of morbidity and mortality in adulthood from the number of these and the proportion of health-harming behaviours and health outcomes that could be prevented if ACEs were reduced. These studies have all used a cross-sectional survey to investigate levels of ACEs and their associations with adulthood lifestyle and disease. Understanding which population groups are most affected by ACEs, how ACEs affect health and social wellbeing and the burden they place on public services is fundamental in developing effective local responses. This research will contribute to our understanding of ACEs and the availability of such data on ACEs and their impacts is supporting a shift towards investment in prevention and health improvement, particularly where local data are available.

In 2013/14 a Routine Enquiry into Childhood Experience (REACh) training programme was developed and piloted among universal and targeted services individually in the borough of BwD (McGee et al., 2015). Briefly, the REACh training was designed to increase service providers’ awareness of ACEs and encourage practitioners to embed routine enquiry into daily working practices. The pilot work in the borough of BwD is currently being developed into a multi-agency (rather than individual agency) REACh training programme for services within the East Locality Transforming Lives partnership. The multi-agency REACh training seeks to create a sustainable model so that line mangers (rather than trainers) can support frontline staff to undertake routine enquiry and respond appropriately to disclosures. BwD Public Health has commissioned the Centre for Public Health to undertake an evaluation to explore the impact of a multi-agency REACh training programme on participant knowledge and confidence in asking and responding to disclosures, as well as its impact on working practices among services within Transforming Lives.

The violence and nightlife team at CPH are also currently undergoing a systematic review looking at the impact of ACEs on long term health outcomes, health risk behaviour, mental health, criminal justice and violence across the life course.


Bellis MA, Hughes K, Leckenby N, et al. National household survey of adverse childhood experiences and their relationship with resilience to health harming behaviours in England. BMC Medicine 2014a; 12: 72.

Bellis MA, Hughes K, Leckenby N, et al. Measuring mortality and the burden of adult disease associated with Adverse Childhood Experiences in England: a national survey. Journal of Public Health 2014b; doi: 10.1093/pubmed/fdu065.

Bellis MA, Lowey H, Leckenby N, et al. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health 2014c; 36: 81-91.

Felitti MD, Anda RF, Nordenberg MD, et al. 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 1998; 14: 245-258.

McGee C, Hughes K, Quigg Z, Bellis MA, Larkin W, Lowey, H. (2015) A scoping study of the implementation of Routine Enquiry about Childhood Adversity (REACh). Liverpool: CPH. Available from http://www.cph.org.uk/wp-content/uploads/2015/07/REACh-Scoping-Study-BwD.pdf