ACEs are highly stressful, and potentially traumatic, events or situations that occur during pregnancy, childhood and/or adolescence and can have an impact on physical and mental health throughout life.
There is no definitive ‘list’ of ACEs and ongoing research continues to add to an understanding of ACEs and the risks associated with them.
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, studies addressing the issue have mostly converged on a similar set of experiences falling under this term.
These are listed below:
These are examples of experiences that can be traumatic but it is important to remember that some of these experiences may be more traumatic for some people than others. There are also other experiences which can be traumatic that are not included in this list.
This concept of the ‘Pair of ACEs’ Tree proposes that ACEs and trauma are not limited to individual experiences but can also be linked to the environment in which these are experienced (read about this framework in the source document here). People living in adverse community environments might find it harder to contain their levels of stress.
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. For more information, see The ACE Index: Mapping Childhood Adversity in England.
Most research studies on the subject of ACEs have focussed on a broad range of long term health-related outcomes but links have also been reported between ACE exposure and experience of wider social problems such as reduced educational attainment, worklessness, diminished social mobility, lower socioeconomic status and risk of an individual’s involvement with the criminal justice system.
People who have experienced trauma often develop coping strategies that relieve distress temporarily but repeated use becomes health harming and the disease burden increases. However, research has shown that even people who had experienced ACEs but had no health harming behaviours, still had increased risk of non-communicable diseases.
The triangle diagram shown here (fig.2) illustrates the life course impact expose to toxic stress can have.
Evidence suggests that risk to health and wellbeing increases with the number of ACEs a person experiences. The table shown here (fig.3) provides some examples of these risks.
Experiencing childhood adversity is correlated only to a higher risk of experiencing certain problems in later life. Access to support can mitigate the risk of negative experiences in later life. Nevertheless, the prevalence of some conditions rises significantly with the number of ACEs that individuals have experienced.
Read more about the impact of ACEs: Commons Select Committee report: Evidence-based early years intervention
Read the seminal 1998 ‘ACE Study’ of over 9,000 adults in San Diego: Felitti et al., ‘Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults’, American Journal of Preventive Medicine vol 14 (1998)
Evidence submitted to the Commons Select Committee cited:
The National household survey of adverse childhood experiences in England found 9% of English adults had experienced four or more ACEs. Research in Wales found 14% of the population had experienced 4 or more ACEs.
You can read more about prevalence in England the ‘National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England’
We are developing a Chapter on ACEs within our local Joint Strategic Needs Assessment (JSNA). This will be available here once published. You can access the full Bristol JSNA on the Bristol City Council Website.
A 2019 evidence review identified four common approaches to preventing and mitigating the impacts of ACEs and trauma:
The report provides details on the common components, interventions and settings within each of these.
The research suggests these strands of work need to be supported by ongoing awareness raising of the causes and consequences of ACEs and trauma. This applies across the workforce and is not limited to specialist professional groups.
What we can all do:
Whilst concerted efforts are also needed to reduce exposure to ACEs and trauma, strengthening resilience in children and adults is important to protect against the impact of ACEs through the life course.
The role of resilience as a protective factor to mitigate the impact of ACEs is increasingly evident. Recent studies have shown that resilience resources in childhood and adulthood can moderate the negative outcomes associated with ACEs and show protective effects on mental ill health, childhood health and educational attendance.
Childhood resilience resources which help prevent the negative impact of ACEs include having a stable trusted relationship with an adult, participating in sport clubs and strengthening social and emotional competency (protective skills).
Sources of resilience amongst adults shown to be important mitigating factors include regular participation in community activities and perceived financial security.
It is important to ensure that service responses do no re-traumatise individuals; that service providers identify and address the barriers that those affected by trauma can experience when accessing the care, support and treatment they require for a healthy life. It is important that we recognise that trauma is common and understand that these experiences might have a range of impacts.
All organisations can work towards being trauma informed by ensuring that physical environments, staff behaviour and organisational policies and procedures reflect trauma-informed-principles and values. Organisations also need to consider and respond to the needs of workers in responding to people affected by trauma.
Whilst a number of evidence-based interventions target specific types of adversity (e.g. domestic violence), we know that ACEs are strongly correlated; individuals exposed to adversity are often exposed to more than one type. This means adversity requires a whole system approach which extends across sectors including health, social care, policing, education, housing and community, and across the life course from early childhood through to adulthood.
There remain gaps in evidence and understanding in relation to effective multi-sectoral responses to ACEs (as a collective group of childhood stressors) rather than responding to individual ACE types, to break the intergenerational cycle of ACEs.
For further information and links to the research studies referred to in this section, see: Responding to Adverse Childhood Experiences: An evidence review of interventions to prevent and address adversity across the life course. Public Health Wales, Cardiff and Bangor University, Wrexham
You can also read more about evidence based approaches to addressing ACEs in this report: Adverse childhood experiences: What we know, what we don't know, and what should happen next, Early Intervention Foundation, 26 February 2020
We set out our ambition to work towards being a trauma informed city in the Bristol One City Plan. We aim to be a city where we can disrupt the intergenerational cycle by preventing ACEs in our young people and strengthening resilience in individuals, families and communities, leading to better life outcomes.
Find out more about the Bristol One City Plan.
A series of local task and finish group meetings were held to develop our local approach to this work. This included over 40 different partner organisations and led to the agreement of the following approach:
Our Principles: Strengths based, evidence informed and sustainable.
A report produced through the Task and Finish Group is available here.
The strongest criticism of the ACE lens relates to the practice of summing the number of ACEs experienced to determine an ACE ‘score’, and the misapplication of this ‘ACE framework’. Locally our approach does not promote screening in this way or service models where we ‘count ACEs’. Our emphasis is on understanding the life-course impacts of childhood adversity on children, adults and the wider community.
Collectively, we want professionals who work with children and families, and vulnerable adults to have a better understanding of the root causes of presenting behaviours, rather than “treating” the presenting behaviour, and to have a better understanding of people’s lived experience.
We have established an ‘Adverse Childhood Experiences Health Integration Team’ to bring multi-disciplinary partners together to develop our local approach and drive culture change and practice. This is a collaboration across Bristol, North Somerset and South Gloucestershire. It engages partners across the voluntary and community sector, the BNSSG Clinical Commissioning Group and health care providers, Avon and Somerset Police, Education, the University of Bristol and the University of the West of England, Children and Family Services, Public Health, and Adult Social Care.
You can read more about the Health Integration Team model here
This local partnership will be:
There are three active work streams within this partnership that cover Bristol, North Somerset and South Gloucestershire:
Bristol also has an Education workstream which is brings together partners across early years settings, schools and academies. This group works in partnership with the Local KBSP Education Reference Group to implement strategic changes in safeguarding practice across the Education Workforce.
We are working with children and young people, parents and carers, and local communities to develop our work at steering group level as well as in the workstreams and through individual projects.
More Information: Bristol Health Partners: Health Integration Teams
The Trauma Subgroup of the Bristol, North Somerset and South Gloucestershire Mental Health Partnership have led work on a Knowledge and Skills Framework for Trauma Informed Practice. The Knowledge and Skills Framework lays out the essential knowledge and skills needed by all tiers of the workforce. This framework describes the knowledge and skills required by individual workers and their organisations to become adversity and trauma informed, to recognise the potential long-term impacts of these experience on themselves, on the individuals, families and communities with whom they work and to respond in compassionate and timely ways that help to support recovery and prevent further harm.
The framework also aims to support managers and supervisors to recognise the educational, emotional and practical support required for their workforce to become adversity and trauma informed as the workforce itself is not exempt from the impact of adversity and trauma.
Every member of the workforce has a part to play in ensuring that organisations are adversity and trauma informed. We hope that training in adversity and trauma awareness will create a shared understanding, language and value system across different teams and organisations. While the whole system needs to become adversity and trauma informed, the specific knowledge and skills required varies depending on an individual’s role.
The framework is accompanied by an implementation toolkit. These documents will be updated based on feedback and our ongoing learning. Please send any feedback to ACEHIT@bristolhealthpartners.co.uk
A set of principles for Trauma Informed Practice have also been developed and are being embedded in policy and practice across the area.
The framework, toolkit and principles are available here:
Towards an ACE Aware Bristol
Building on work initiated in South Gloucestershire, Bristol is developing a network of ACE Ambassadors who are championing culture change and helping to embed new ways of working in their workplaces and communities.
Bristol now has almost 100 trained ACE Ambassadors across different organisations including social care, police, health, education and voluntary sector organisations. These Ambassadors are able to deliver ACE Awareness briefings. If you would like to join this network or link with an Ambassador please do get in touch at ACE@Bristol.gov.uk.
The Keeping Bristol Safe Partnership also offers relevant learning opportunities, visit the KBSP Training page to download the training programme.
Our local Knowledge and Skills Framework was developed with thanks to NHS Scotland Transforming Psychological Trauma Framework and the Welsh support hubs skills and knowledge framework:
Researchers and practitioners are working together to build the evidence base around childhood adversity and trauma, and to harness the best research, innovation, care and education to make a difference to people's health and wellbeing.
We are working together with the University of Bristol and the University of the West of England, and are developing a programme of work with our local National Institute for Health Research (NIHR) Applied Research Collaborative (ARC West). ARC West is prioritising work in this area within their Healthier Childhoods Research Theme.
Details of Healthier Childhoods research projects will be available here.
The ACE Health Integration Team and ARC West are committed to involving children and young people, family members and other members of the public in our research to support evidence-based improvements. You can read more about this work here.
The impact and relevance of ACEs and trauma is being considered in the development of all local strategies, plans and relevant transformation programmes, ensuring the risks associated with exposure to adversity are recognised and understood.
We are taking a ‘life-course’ approach and looking across the system to identify gaps in provision at particular points along the life course and in system integration, across for example, social care, education, health, policing, housing, city planning and the inclusive growth agenda.
We will be developing guidance and tools to enable commissioners to embed trauma informed practice through commissioning. This will include trauma informed commissioning guidance for policy makers and commissioners, with sample tender paperwork and policy standards which promote core competencies around trauma informed practice within our contractual frameworks and expectations with regard to staff training for example.
Education leaders and partners across school communities are working together to develop an evidence based approach for effective ACE and trauma informed practice in education settings in Bristol, in line with their statutory safeguarding duties.
We are actively working to develop safeguarding practice with a view to increasing understanding of the impacts of trauma and adversity across the education workforce and school communities. Guidance and resources will be made available to help embed trauma informed practice in education settings, within the context of multi –agency working arrangements.
The Education Workstream are currently:
Some school based resources are available in the Support and Resources section. Additional resources will be made available on this page in due course. If you would like to help develop and test resources or if you have good practice to share please contact ACE@Bristol.gov.uk
This section will be updated with resources as local work progresses.
Meeting the needs of people who have experienced ACEs and trauma is not always about providing or referring to an additional service, for many it is about a way of working and practitioners understanding the impact of adversity and responding appropriately. The Keeping Bristol Safe Partnership (KBSP) offers a range of learning opportunities. Visit the KBSP Training page to download the KBSP Inter-agency Training Programme.
Additional guidance and training opportunities are also available for the Education sector, access these at the Safeguarding in Education webpage.
The following resources and links signpost to organisations that are able to offer advice and support but you should make a referral to First Response if you have concerns that a child is being abused or neglected, or if you want to request support on behalf of a child or family. More information on how to do this is available here: First Response
This leaflet signposts to a number of organisations that are able to offer support to individuals who are affected by ACEs and Trauma.
Supporting parenting and building resilience in parents can help prevent and mitigate the impacts of ACEs. Information about parenting courses, advice and support in Bristol is available here.
Research suggests that sports participation has a strong impact on resilience. You can find out about leisure centres and sports facilities here.
Bristol Educational Psychology Service offer a range of interventions that focus on developing key resilience factors such as trusting adult relationships, developing social and emotional skills and wellbeing strategies. Each school in Bristol has a link Educational Psychologist with whom they negotiate a contract of work for each academic year. As part of this contract of work, the following interventions are available. For more information about how to access this support please visit the Trading with Schools website.
Staff training and supervision
Safeguarding within settings
In this beautifully animated RSA Short, Dr Brené Brown reminds us that we can only create a genuine empathic connection if we are brave enough to really get in touch with our own fragilities. This video explains the difference between empathy and sympathy well and is also a nice reminder for us about how to choose our words.
A free online course, funded by the Home Office Early Intervention Fund, for practitioners, professionals and volunteers who work with children, young people and their families. It will take approximately 50 minutes to complete.
A TED MED Talk by Nadine Burke Harris from 2014.
An inspiring and informative one hour documentary made by KPJR Films (2016) on the effects of ACEs and how to overcome them. To screen the film in your organisation or with a local network or partnership please contact: ACE@bristol.gov.uk - Currently unavailable
This short animated film has been developed 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 film has been produced for Public Health Wales and Blackburn with Darwen Local Authority. Further information available here.
Learning how to cope with adversity is an important part of healthy development. While moderate, short-lived stress responses in the body can promote growth, toxic stress is the strong, unrelieved activation of the body's stress management system in the absence of protective adult support. Without caring adults to buffer children, the unrelenting stress caused by extreme poverty, neglect, abuse, or severe maternal depression can weaken the architecture of the developing brain, with long-term consequences for learning, behavior, and both physical and mental health.
This video is part three of a three-part series titled "Three Core Concepts in Early Development" from the Center and the National Scientific Council on the Developing Child. All available in the link.
This video explores what we know about how trauma and exposure to unhealthy levels of stress hormones (e.g. cortisol and adrenaline), can adversely affect the structure and functioning of a child’s developing brain
A video created in Avon & Wiltshire Partnership Mental Health Trust which gives an overview of trauma including the differences between single-event and complex trauma.
An animated video created by NHS Lanarkshire and partners which shows two police detectives interviewing a young lady who is reporting rape, and how they learn to take a trauma-informed approach to interviews once they have attended trauma training. Shows the impact of trauma on the brain, particularly on memory.
A short animation showing how primeval people used the fight or flight responses for survival, but how the automatic response may at times be unhelpful in the modern world.
A short animation explaining the human responses of fight, flight or freeze which are used for survival, and the physical sensations felt in the body.
An animated video by Dr Russ Harris which explains how survival skills which were once essential for survival can be less helpful in the modern world. The video shows that difficult thoughts and feelings are part of normal human responses.
An animated video by Dr Russ Harris which describes what happens in the brain during trauma. The video uses four metaphors to explain brain function: the Data Analyst, Emergency Alarm, Security Guard and Mission Control.
A video explain the impact of trauma on the brain, specifically that it can become ‘stuck’ in survival mode which makes it more challenging to learn and remember new information.
This video shows an animal using the automatic ‘flop’ response to survive an attack.
An animation showing the impact of trauma on a child’s 'window of tolerance' of emotions, and the importance of widening the window.
An overview of attachment theory including the different attachment styles.
Handouts for teachers or trusted adults at school/college to help understand what survival states look like in the school/college environment and what they can do to help ground them and subsequently improve their learning
What does School feel like for children and teens living with trauma pain? This video is a collation of some of their voices and why Schools urgently need training and support to become trauma and attachment aware environments. Made by parents of children with trauma. Relevant even if you don’t work in a school: consider these examples to think about possible triggers in your working environment or in your working pattern.
Dr Karen Treisman with Safe Hands and Thinking Minds Associates draw on a range of interdisciplinary expertise, theoretical perspectives, and evidence bases to promote, solidify, and develop high standards in areas of parenting, trauma, adversity (ACE’s), attachment, fostering, adoption, asylum-seeking & refugee young people, and culturally/adversity/trauma-informed and trauma-responsive organisations. The website signposts to an array of useful content, podcasts, resources, reading and links in the areas of trauma, toxic stress, attachment, foster care, adoption, and parenting.
Beacon House develops freely available resources about trauma and adversity. Resources include this Comic Strip illustration of how a shift from traditional language to trauma informed descriptions of vulnerable individuals can create compassion instead of blame, hope instead of hopelessness and connection rather than disconnection.
North Somerset: Trauma Informed Practice (43 minute video) A film made locally about trauma informed practice. Click on the link to download the MP4 file.
Additional videos for Psychoeducation and skills have been compiled here, collated by Sally McGuire, Clinical Psychologist
The Bristol City Council website includes information about where to find guidance for staying physically and mentally well during coronavirus (COVID-19)
Young Minds: Advice for parents and carers- talking to children and young people about coronavirus
Safe Hands Thinking Minds: Resources for supporting children and young people with worry and fear: Tips, tools and resources
Beacon House: Covid-19 support resources
Covibook: an interactive resource designed to support and reassure children aged 7 and under, designed to help children explain and draw the emotions that they might be experiencing (different languages)
Carers UK: Guidance for carers
Child Bereavement UK: Help for children and young people, parents and families to rebuild their lives when a child grieves or when a child dies
Winston’s wish: Information, advice and guidance on supporting bereaved children and young people during the coronavirus outbreak. Free phone number for children 08088 020 21 plus online information
A wide range of resources and further reading have been collated on this Trello page, made available by partners in South Gloucestershire. This link will not open in Internet Explorer – please use an alternative browser, such as Chrome.
Adverse childhood experiences: What we know, what we don't know, and what should happen next, Early Intervention Foundation, 26 February 2020 This report surveys the evidence relating to the prevalence, impact and treatment of 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.
‘Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland’ The Scottish Public Health Network (ScotPHN) report provides an overview on ACE and makes a number of recommendations.
Welsh Adverse Childhood Experiences (ACE) Study Report relating to Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population.
National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England, Bellis et al., BMC Medicine vol 12 (2014)
‘Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study’, Felitti, M. D., Anda, R. F., Nordenberg, M. D. et al (1998) ‘American Journal of Preventative Medicine. 14. Orignial US Study or sourced here.
Current programme in England - ‘Creating ACE-informed places: promoting a whole-system approach to tackling adverse childhood experiences in local communities’, Association of Directors of Public Health. This project will scale up tested approaches in order to share good practice and stimulate an England-wide response to tackling ACEs. The project will bring together key partners – including the police, public health professionals, health care professionals and children’s social services – to discuss the current evidence base and identify what work has already been done to tackle ACEs in areas of the UK.
For any enquiries relating to Bristol work on ACEs and trauma informed practice please contact ACE@Bristol.gov.uk