Review of Adverse Childhood Experiences (ACE) policy: report

I welcome the publication of this report on the review of the Welsh Government’s Adverse Childhood Experiences, or ACEs, policy. The report brings together the main findings and conclusions from the review and provides an invaluable resource which will help inform the Welsh Government’s future ACEs policy. I would like to thank all of those who contributed to the review, particularly those who participated in the discussion. Their willingness to share their views on ACEs, on the Welsh Government’s ACEs policy and how the policy should be developed in the future, have enriched the review and I am grateful for their expertise. I would also like to thank Re:cognition for their assistance in capturing the views of stakeholders.

This government is committed to ensuring all children in Wales have the best start in life and the opportunity to achieve their potential. This means working to tackle the barriers which might prevent this, including childhood adversity in all its forms. The term ACEs has been in use for over 20 years to describe a set of ten specific events and circumstances. Studies from across the world have consistently demonstrated a strong association between ACEs and poorer outcomes across the life course. This includes the studies in Wales from Public Health Wales, which were influential in the Welsh Government’s decision to prioritise action on ACEs during this Assembly term.

The review has demonstrated the existence of a robust body of consistent evidence underpinning ACEs and strong support for the Welsh Government’s decision to prioritise action on ACEs. It has also shown strong support amongst stakeholders for having an ACE Support Hub for Wales. The review has demonstrated how the recognition of ACEs has become well embedded across Welsh Government policy and, pleasingly, how the Welsh Government’s adoption of ACEs has influenced the development of UK Government policy in some non-devolved areas.

We have made significant progress on delivering our commitment to create ACE aware public services in Wales. We can already see some of the benefits of the work undertaken to raise awareness and understanding of ACEs in areas such as education, youth justice and housing.

Despite the good progress we had made, there is more we need to do. We need to ensure the greater awareness and understanding of childhood adversity translates into action which makes a positive difference. We need to find the best ways to support parents, protect children from harm, give them the best start in life and improves outcomes.  This includes action which prevents ACEs and mitigates their impact.

This is not just about our public services. We all have a role to play, as individuals and members of our communities, in preventing childhood adversity and mitigating its impact. This begins with an understanding of the long term effect which childhood adversity can have and responding accordingly. It also means helping children and young people, families and communities, to develop their resilience and ability to bounce back from adversity.

Most services and professionals have acknowledged the need for action on ACEs. However, I am aware that there are some who continue to question ACEs and it is important we acknowledge these concerns. One of the main concerns is around the possible misuse of the ACE score and its misapplication with individuals to determine when and how to intervene. These are valid and understandable concerns which we must consider in developing our future ACEs policy.

The review has highlighted areas where we need to make improvements, not least in using the increased awareness and understanding of ACEs to change the way we configure our support services and the interventions provided. It has clearly identified a number of areas where stakeholders are looking to the Welsh Government to provide clear policy direction.

I have asked my officials to convene a task and finish group to consider the findings of the review and make recommendations to ministers about how the Welsh Government’s ACEs policy should be developed. I want the group to comprise external stakeholders and Welsh Government officials from a range of policy areas. I would like the group’s work to be guided by the following principles, which I believe are very important:

• Adverse Childhood Experiences are not inevitable. Where possible, the focus of ACEs work should be on preventing childhood adversity from happening in the first place. However, we cannot ignore the need to provide sympathetic responses and trauma informed support to those who have already been impacted by ACEs or the importance of adopting a strengths based approach and building resilience.
• Our approach to raising awareness of childhood adversity should support parents and must avoid unintended consequences, like stigmatisation or increasing preventable statutory interventions. A narrow focus only on parental behaviours should also be avoided. Preventing adverse childhood experiences requires attention to the wider social and economic contexts of family life.
• We need to be careful in our use of the term ‘Adverse Childhood Experiences (ACEs)’, as well as the language we use to describe adversity, and be mindful of its impact. ACEs should never be viewed as being deterministic.
• The ‘ACE score’ should not be used with individuals to determine risk or whether or not to offer an intervention or the type of intervention which should be offered.   
• Work on adverse childhood experiences should reflect that ACEs are more concentrated in deprived areas. It needs to recognise that poverty and multiple deprivation are causal factors in at least some of these adversities.
• We should recognise, support and promote the contribution that community-based, self-help and peer support approaches can make in preventing childhood adversity and mitigating its impact. 

I have also asked the ACE Support Hub, which I have agreed to fund for another year, to be guided by these principles in its work.

It is more important, than ever, for us to take action on childhood adversity. The coronavirus pandemic has again highlighted the significant inequalities which exist in our society and how some children and families are disproportionately affected.  Evidence already suggests that childhood adversity has increased as a result of COVID-19, particularly in some of our most disadvantaged and vulnerable communities. The ACEs evidence already tells us what the long term implications of this could be if we don’t act. I am sure the impact of COVID-19 on our children and young people, families and communities will be at the forefront of the task and finish groups thinking. I very much look forward to seeing the outcomes of the task and finish groups work.

Julie Morgan MS

Deputy Minister for Health and Social Service

Background

Adverse Childhood Experiences (ACEs) refer to traumatic events or circumstances which happen in childhood which can lead to poorer outcomes across the life course. ACEs include child maltreatment (physical and emotional abuse and neglect) and wider experiences of household dysfunction (domestic violence, parental separation, substance misuse, mental illness or parental incarceration). These experiences can result in poorer physical and mental well-being, educational outcomes, relationships with others and economic prosperity. They can also increase the likelihood of coming into contact with the criminal justice system.Studies from around the world, including Wales, consistently link ACEs to a greater likelihood of developing a range of chronic diseases, like respiratory illnesses, cardiovascular disease or cancers, and with poorer mental well-being. They indicate the risk increases exponentially so, as the number of ACEs increases, so does the likelihood of encountering poorer outcomes. However, the link is an association rather than deterministic. Those who experience ACEs, even multiple ACEs, will not necessarily go on to experience poorer outcomes. This is because there are many other factors which can influence someone’s life outcomes. While ACEs cannot be used to predict who will or won’t go on to experience poorer outcomes, they can be used to identify the potential prevalence of poorer outcomes at a population level.
 

The Welsh Government’s decision to prioritise tackling ACEs was informed by the findings of a 2015 Public Health Wales (PHW) study into ‘The prevalence of Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population[1]’. A follow-up study in 2017 and a range of other reports published subsequently, have helped inform the ongoing development of the Welsh Government’s ACEs policy.

The 2015 study indicated ACEs were fairly common, with around half of all the adults in Wales having experienced at least one ACE. By the age of 49 years, 24.9% of individuals with four or more ACEs reported having been diagnosed with one or more chronic diseases. The figure was 6.9% in those with no ACEs. The levels of chronic disease diagnosed in those with four or more ACEs were similar to individuals aged around ten years older with no ACEs. Compared to those with no ACEs, those who had experienced four or more ACEs were: four times more likely to be a high-risk drinker; six times more likely to have had sex under the age of 16 years, to have had or caused unintended teenage pregnancy, and to smoke; and were sixteen times more likely to have used crack cocaine or heroin. Compared to those with no ACEs, those with four or more ACEs were fifteen times more likely to have committed violence against another person in the last 12 months and twenty times more likely to have been incarcerated at any point in their life.

The publication of the PHW ACEs study prompted Cymru Well Wales (CWW), a collective of public and third sector organisations, and others, including the Future Generations Commissioner, to call upon the Welsh Government to take action to prevent ACEs. In particular, CWW called for action to:

• reduce the number of ACEs in Wales;
• make all public services in Wales able to respond effectively to prevent and mitigate the harms from ACEs (be ACE informed); and
• build protective factors and resilience in the population to cope with ACEs which could not be prevented.

In addition, CWW called for the establishment of an ACE Support Hub for Wales (Hub) as a centre of knowledge, evidence and expertise on ACEs.

The Welsh Government made tackling ACEs a priority for this Assembly term. It set out its commitment to tackling ACEs in its programme for government, ‘Taking Wales Forward[2]’, and how it intended to do so in ‘Prosperity for All: the national strategy[3]’. Taking Wales Forward acknowledged ACEs as a barrier to all children having the best possible start to life and recognised the need to support families to reduce ACEs. Prosperity for All included action to prevent ACEs and mitigate their impact by creating ‘ACE aware’ public services, building children and young people’s resilience and piloting Children First, a community led approach to reducing ACEs and improving resilience. The Welsh Government also agreed to support the establishment of an ACE Support Hub for Wales.

The ongoing development of the Welsh Government ACEs policy has been informed by a second PHW study of ACEs in Wales (2017) and a range of other reports looking at specific aspects of ACEs. This included the impact of resilience as a protective factor and mental well-being (2018)[4], and the prevalence of ACEs in more vulnerable populations, including the homeless, male prisoners and refugee and asylum seekers. The policy has also been influenced by the work of the Hub and the Early Action Together Programme (EATP)[5], and by learning from a range of training pilots, including for the housing and homelessness sector, schools, youth justice and youth services.

Good progress has been made towards the establishment of ACE aware public services in Wales, and the Children First pilot is operating in eight Welsh communities. The Hub has played an instrumental role in raising awareness of ACEs, not least through its development and support for the delivery of awareness training programmes. It has delivered a comprehensive training programme to over 600 schools and more than 1,100 housing officers. Training has been given to over 300 ACE Ambassadors, 140 Estyn inspectors and challenge advisors, 120 youth workers and 95 ‘train the trainers’. The Hub has also supported services to go beyond this by working to become trauma informed. By the end of the EATP, in March 2020, nearly 6,500 police officers and staff working in other organisations had received ACE awareness training through the EATP’s ‘ACE Time Training’ programme. 

Many public services have readily applied an ACE lens to their services and have made available ACE awareness training to their staff. However, some services have been more reluctant to do so, questioning the validity of the ACEs approach. With this in mind and as the programme for government and its current commitments come to an end, the Deputy Minister for Health and Social Services requested a review of the Welsh Government’s current ACEs policy to help inform its future direction.

The main aims of the review were to look at how the policy was contributing to the delivery of the Welsh Government’s overarching aim of ensuring all children in Wales had the best start in life and opportunity to achieve their potential, and how the policy should develop in the future. The scope of the review was to consider the:

• current Welsh Government policy on ACEs and how it contributes to preventing ACEs and giving all children the best start in life
• current evidence base, particularly any new evidence published during the current Assembly term
• current language of ACEs and its impact on work to prevent ACEs and mitigate their impact
• current awareness and understanding of ACEs among professionals and the general public and
• role of the ACE Support Hub for Wales.

The review was conducted in two phases. The first involved a desk-based review of the literature and evidence which informed the Welsh Government’s ACEs policy at the overarching and individual policy area level. 

Phase 2 comprised a ‘discussion’ with stakeholders about their views on the Welsh Government’s ACEs policy and how it should be developed in the future. The discussion with external stakeholders was conducted by independent consultants, Re:cognition, while discussions with Welsh Government policy leads were conducted by officials from its Children and Families Division.

Some of the main findings from the evidence and literature review included:

• There was a substantial and consistent body of evidence demonstrating the strong association between ACEs and poorer physical and mental health, and other outcomes, across the life course. 
• ACEs are common. Around half of all adults will have experienced at least one ACE.
• The more ACEs experienced, the greater the likelihood of experiencing poorer outcomes.
• ACEs are more prevalent in vulnerable populations. For example, while around 14% of adults in the population will have experienced four or more ACEs, this rises to nearly 50% in the male prison population and in those with lived experiences of homelessness.
• Action to prevent ACEs and mitigate their impact can have significant benefits for individuals, their families, communities and society in general. Action can help reduce current and future demand on public services.
• ACEs are a barrier to giving children the best start in life and the opportunity to achieve their potential. Having an ACEs policy is therefore consistent with, and supports the overarching aims of, the programme for government and national strategy.     
• Action taken to tackle ACEs has been taken across a broad range of policy areas. There has already been a significant investment in time and resources, including by the Welsh Government, to make public services ACE aware and trauma informed.
• A significant number of Welsh Government policies, strategies, delivery plans and programmes have already applied an ‘ACE lens’ to their development, including in the areas of substance misuse, education, violence against women, domestic abuse and sexual violence, housing and crime and justice. Some of these policies have been approved at cabinet level in both the Welsh Government and external bodies, like local authorities.

Phase 1 clearly showed how an awareness of ACEs and their impact has become embedded within many policy areas and public services. This work has been augmented by a public awareness campaign[6]. Phase 1 demonstrated how the evidence base, awareness raising, adoption of a common language, and  understanding of the benefits of developing ACE aware and trauma informed services, has influenced and changed the policy landscape in Wales. This has not only been driven by the Welsh Government’s adoption of the ACEs framework centrally, but by the work of others outside of government. The Welsh Government’s adoption of ACEs has even influenced the development and direction of some UK government policy on non-devolved areas.  

What is not yet clear is what impact the ACEs policy has had on improving outcomes and which actions and support can make a positive difference. As we are looking at the impact across the life course, it might be many years, even decades, before the full impact of the decision to adopt the ACEs framework will be known.

Raising awareness of ACEs in public services is just the first step and, in itself, is unlikely to deliver the best possible start in life for children or opportunity to achieve their potential. It is important that we have a clear understanding about which interventions make a positive difference and about who should receive them and when. There are, however, already some promising early signs about how even an awareness and understanding of ACEs can make a real difference. For example, work to raise awareness of ACEs in schools has already been shown to make a positive difference in pupil’s behaviour, attendance and educational outcomes.

As well as looking at the strengths of the current evidence base for ACEs, Phase 1 considered its limitations. It investigated why there are some who express concerns about or opposed the adoption of the ACEs framework. These concerns were not specifically directed towards the Welsh Government’s policy.

Concerns included:

• The ACEs studies are epidemiological research and only seek to identify the patterns and probabilities of disease at a population level, their underlying causes and how to prevent them. There were concerns expressed about the potential for misuse of the ‘ACE score’. This was developed for research purposes. It was not designed to be used with individuals to determine risk, whether or not to offer an intervention, or the type of intervention which should be offered.
• ACEs pathologises societal problems and seeks to apply clinical solutions to them. The approach tends to individualise the problems and place the responsibility largely on parental behaviours. It places the responsibility for improving outcomes upon parents for issues over which they may have minimal control or influence or ability to address.
• The ACEs framework ignores other sources and forms of adversity, like childhood illness, disability, bullying or bereavement; or the impact of other factors like structural and social inequalities, including poverty.
• It treats all ten ACEs exactly the same and does not account for the impact of factors like when the ACE happened, its severity, frequency or duration, or the individual’s personal traits or support available to them, which could  amplify or reduce the impact.
• There is a danger of bad practice forming around ACEs, e.g. the counting of ACEs, rather than focusing on their impact to determine when and how to intervene and with whom.
• ACEs represents a simplistic way of explaining the complex nature of the relationship, interdependencies and pathways between childhood adversity and trauma and life outcomes. ACEs are not deterministic and many who experienced ACEs will not experience poorer outcomes. There is a danger it will overly simplify and generalise our understanding of every child’s individual and unique experiences and life pathways, which could lead to policy makers wrongly labelling segments of society as being deficient in some way and developing their policies accordingly. 
• The strength of the association between ACEs and poorer outcomes, and the impact of other factors which can influence the same outcomes. There is evidence suggesting the association between ACEs and poorer mental health and well-being is stronger than for some physical health conditions.
• Some see the ACEs approach as being based on deficits rather than strengths and have the potential to be used to blame, label and stigmatise those which it purports to help.

These valid concerns need to be kept in mind in developing the Welsh Government’s ACEs policy.

The Welsh Government recognises there are other forms of childhood adversity and trauma which can influence someone’s life chances and outcomes. It recognises there is a complex, inter-relationship between ACEs and other sources of childhood adversity and trauma and work is still required to understand these relationships. This is particularly true of the relationship between childhood poverty and ACEs.

Phase 1 of the review identified a series of questions to be put to stakeholders during the Phase 2:

• Is the current evidence on ACEs sufficient to determine the Welsh Government’s approach to improving outcomes for children, including giving all children the best start in life and opportunity to achieve their potential? If not, what other evidence do we require?
• Is taking a public health approach to tackling ACEs and mitigating their impact the right approach and why? If not, what should the approach be?
• How can the evidence from the epidemiological population level ACE studies be used to inform the development of policies, programmes, services and interventions delivered at the individual level?
• What is the relationship between the Welsh Government’s current ACEs policy and its policies to address wider adversity and inequalities which also impact on the life chances and outcomes?
• How effective has the ACE Support Hub been in supporting the Welsh Government’s commitment to raise awareness of ACEs and build resilience in public services, communities and families?
• What role, if any, should the ACE Support Hub have in the delivery of Welsh Government policy in the future?
• Does the term Adverse Childhood Experiences (or ACEs) support or undermine the Welsh Government’s wider aims? What are the advantages and disadvantages of any alternatives which may be used? 
• What is meant by trauma informed practice?
• What should the Welsh Government’s policy position be on routine ACE enquiry?
• The work undertaken in Wales on ACEs has been held up as an example of good practice in the UK and internationally. How might this be developed further?
• How should the Welsh Government’s policy on ACEs reflect the likely impact of the COVID-19 pandemic?

Main findings of the discussion with external stakeholders

Between September and December 2020, Re:cognition spoke with 33 individuals representing a diverse cross-section of services and professions. This included professionals working within and outside Wales and those who were in support of and against ACEs. In addition, they held three group sessions which involved a further 27 stakeholders. While the sample was not a representative cross section of stakeholders, it did represent a broad range of services, professionals and academics with relevant views on ACEs.

Overall, there was a great deal of support for the adoption of the ACEs framework in Wales and for the work which had been done by the ACE Support Hub to raise awareness of ACEs.

The discussions found little evidence which supported concerns about the misuse of ACEs. While some stakeholders said they had heard of instances, they were unable to identify specific examples. Four areas of concern which were identified were:

• The ACEs framework fails to recognise, nor attempts to address, the complexities of social, economic and structural causes of trauma, such as poverty, housing, inequality and other socio-economic factors;
• There is a lack of clarity regarding the language and definitions used within the ACE framework, such as ACE aware, trauma informed and other variants which are used interchangeably and have different meanings between service providers;
• The potential for ACEs to be seen as deterministic, labelling and stigmatising; and
• Those who offered a more strategic overview on the relationship between ACE policy and policies to tackle wider adversity and inequality, expressed concerns about what they saw as a ‘piecemeal approach’ which ‘lacked political vision’ and ‘continued to remain a victim of departmental silo thinking’.

In relation to the specific questions identified during Phase 1, the discussion found:

• Nearly all stakeholders acknowledged the existence of a significant and consistent body of evidence linking adversity in childhood to a higher risk of poorer outcomes across the life course. They felt there was already enough evidence to support the need to act on ACEs.
• Having a strong evidence base was seen as essential, as was the need to continue to gather evidence. While it was acknowledged large scale research is expensive, the current lack of good quality, robust evaluations/monitoring data of the programmes, projects or pilots taking place across Wales, was highlighted.
• The Welsh Government’s current policy was seen as having been successful in raising awareness of ACEs in Wales. However, there was a recognition of the need to move into the next phase, which requires a focus on ‘what works’ and support for the ‘development of effective practice’.
• There was support for taking a public health approach towards ACEs.
• Unless working in the field of research, most stakeholders felt unable to comment on the use of epidemiological studies to drive policy development. Those who were working in the field of research agreed using epidemiological studies was an important and effective way to inform the ACE policy direction in Wales; but they acknowledged such evidence did have limitations. 
• Many stakeholders regarded the relationship between the current Welsh Government ACE policy and its policies to address wider adversity, to be overall very good.
• While stakeholders were very positive about the role which the ACE Support Hub for Wales had played, they felt it now needed to shift its attention from raising awareness to ‘what works’.
• With regards to the adoption of the term ‘ACEs’, there was a degree of ambivalence from many stakeholders as to whether it supported or undermined the Welsh Government’s agenda and wider policy aims. 
• Some stakeholders questioned whether the current list of ten ACEs was adequate to understand the full extent of trauma experienced by children and adults and why other systemic issues were excluded.
• There was a general lack of concern about the use of the term ACEs, because of what was seen as the need to focus on other issues. This included the need to address the transformation of systems, processes and practices which inhibit effective early intervention, prevention and mitigation of the impact of ACEs. Many believed the Welsh Government should be focusing on system transformation, rather than whether to continue to use the term ACEs.
• In response to the question about what is meant by ‘trauma informed practice’, there was a lack of consensus. Stakeholders noted there was a wide range of variants currently being used and looked to the Welsh Government to provide a clear steer.
• Most stakeholders did not feel able to comment on whether routine ACE enquiry was appropriate. Stakeholders looked to the Welsh Government to provide the steer, but did suggest more research may be required. Those who did feel able to comment were mostly in support of routine ACE enquiry, but were clear it needed to be appropriately targeted, informed and relevant. A small number of stakeholders expressed strong opposition to the use of any form of ACE enquiry.
• The majority of stakeholders believed Wales was seen as leading on ACEs, but they also felt it would soon slip behind if ACEs was no longer seen as a priority for the Welsh Government.
• Many stakeholders expressed concerns about the impact of the COVID pandemic on ACEs. Many cited as an example, the increased reporting of incidences of domestic violence during the national lockdowns. They advocated the need for urgent action to protect children and young people.

Re:cognition identified four options for consideration by the Welsh Government. They were:

Option 1

For the Welsh Government to end its ACEs policy commitments at the end of the current programme for government.

The benefits identified included:

• Cost savings from the funding currently provided for the ACE Support Hub.
• The option to replace the ACEs framework with another framework.
• It would remove an approach seen by some as problematic.

Difficulties associated with this option included:

• It was the one least supported by stakeholders. Almost all supported the continued use of the ACEs framework.  
• Abandoning the ACEs framework could cause reputational damage to the Welsh Government because of the focus given to it in the programme of government and the time and resources already invested by it, and others, in promoting ACEs. This included the ACE Support Hub.
• The ACEs framework has become embedded across Welsh Government policy.

Re:cognition’s conclusion on Option 1

This option was the least acceptable to stakeholders and only attracted the support of a very small number of them.

Option 2

Phase out the provision of funding for the ACE Support Hub. As funding for 2021-22 has already been agreed, Re:cognition suggested the Hub be asked to focus on some specific areas of work which had been identified during the discussions. This would include:

• undertaking a comprehensive systems-mapping exercise of the whole ACEs landscape in Wales;
• creating a ‘whole system community of practice’ to help create a shared vision for the future direction of the work around ACEs. This should include leadership from the Welsh Government, while at the same time having elements of independence; and
• overhauling training materials, including the Public Health Wales video ‘Adverse Childhood Experiences (ACEs) (Wales)’.

Re:cognition’s conclusion on Option 2

This option attracted support from only a small number of stakeholders. The majority saw the benefits of having an independent ACE Support Hub and supported its continuation - although they did see a need for its role to change.  Many voiced their fears that, without the Hub, the progress made so far would be lost, as would the knowledge base and there would be no one to push forward the agenda.

Option 3

Adopt the ACE Support Hub’s business plan. Re:cognition suggested there would be two main choices:

• The provision of Welsh Government funding for an additional year (2021-2022), which would enable time for some of the actions detailed within the plan to be delivered; or
• The agreement to continue to provide funding over two years (2021-2023), with a tapering of the funding in year two (2022-2023). This would provide time for the Hub to develop, establish and evaluate a number of programmes, as well as enabling it to undertake an ‘end programme’ evaluation with a cost benefit analysis.  

Re:cognition’s conclusion on Option 3

This option would not realise the majority of the stakeholders’ aspirations, which included the desire to see the Welsh Government develop a long-term vision and direction for its ACEs agenda, supported by a strengthened ACE Support Hub, with a focus on systemic change and on ‘what works’ in practice.
 

Option 4

The Welsh Government adopts a ‘systems approach’ to develop and deliver its ACEs policy. This would include the need to:

• Develop a systems map for the whole ACEs landscape
• Provide clear leadership and support in developing a joined-up common vision, supported by a shared understanding
• Create a whole system ‘community of practice’
• Tackle wider adversity through the lens of ACEs
• Support further research and evaluation on what works/is working; and
• Review existing training materials and the use of language.

Re:cognition’s conclusion on Option 4

Option 4 was the most favoured approach amongst stakeholders. They felt the Welsh Government should accept, unequivocally, the case for adopting the ACEs framework had been made and it should now focus on what works. Stakeholders wanted the Welsh Government to clearly set out its policy and the main aims and objectives of the policy. Stakeholders thought the policy should build on the work already done, towards a more coordinated and joined-up ‘systems approach’. Some called upon the Welsh Government to consider how children’s rights can be further embedded at the centre of the ACE policy.

Some stakeholders felt the existing system was not sufficiently ‘joined-up’ and lacked the necessary common vision and understanding. They wanted to see strong and clear political leadership from the Welsh Government and bold decision making.  They called for the Welsh Government to take the lead in developing a common and consistent language, including what is meant by a ‘trauma informed’ approach. 

Stakeholders called for better alignment between key players in the ACEs system, including between the ACE Support Hub, Violence Prevention Unit and Early Action Together Programme.

Stakeholders felt the development of the system and alignment between key players could be supported by the establishment of a community of practice. They felt this could help the Welsh Government to develop a common vision, which could become the driver for future work around ACEs. They felt this vision needed to consider wider adversity, not just ACEs. Most stakeholders felt the ACE Support Hub should have a continuing role in supporting the Welsh Government and others to develop and deliver the ACEs policy.

The policy leads from 13 different policy areas participated in the internal stakeholders’ discussion (See Annex 1). They were asked for their views on the Welsh Government’s current ACEs policy, its impact on their policy areas and their views on the development of any future ACEs policy.

Key findings

• All policy leads were aware of the Welsh Government’s ACEs policy and demonstrated a good understanding of ACEs, their impact and association with poorer outcomes across the life course. They recognised the relationship between ACEs and poorer outcomes was associative rather than deterministic.
• Policy leads were confident about the strength of the evidence base and were very familiar with the findings of the Public Health Wales ACE studies. While for most the ACEs evidence supported the direction which their policy was already taking, for some, it represented something additional to consider in developing their policies.
• The epidemiological evidence on ACEs was seen as being helpful to the development of population level policy, but less so at the individual level in helping to identify ‘what works’, or what constitutes effective interventions.
• Most referred specifically to the role of resilience in protecting people from ACEs and could identify some of the main sources of resilience. All could reference the importance of having an ‘always available adult’ in developing resilience.
• Policy leads understood how the Welsh Government’s central ACEs policy had influenced their policies, but some felt it hadn’t gone as far as it could in becoming a key policy driver. Most also mentioned how the central policy had influenced policy development and service delivery outside of the Welsh Government, including within some non-devolved UK Government policy areas.
• There was recognition that ACEs are only one consideration and action is needed to tackle other sources of adversity associated with the same poorer outcomes. It was seen to be a case of ‘ACEs and these other sources of adversity’ rather than ‘ACEs or these other factors’.
• Most policy leads felt ACEs had helped to provide a common language and understanding about how exposure to childhood adversity can impact on later outcomes and this had helped collaboration between areas and services. Changing the term ACEs was seen as being potentially problematic and detrimental to tackling childhood trauma and adversity.
• Most felt it was too early in the development of the policy to determine its impact. They did note, however, there had already been a significant investment of time and resources and were very concerned about the possible impact which a move away from the current ACEs policy could have. This included on decisions about UK Government policies which had been influenced by the Welsh Government’s policy on ACEs.
• Some policy leads said they had discussed the language of ACEs with their stakeholders and some of them had expressed concerns about its focus being on deficits not strengths. However, many pointed out the Welsh Government’s ACEs policy and the language around ACEs was already evolving and there was now a far greater focus on adversity and trauma. They recognised it was the greater awareness of ACEs which had enabled this to happen. This increased understanding had enabled the development of trauma informed and responsive policies and public services.
• There was minimal appetite to abandon ACEs in favour of another term. It was felt changing the language would lead to confusion and undermine the progress which had already been made.
• While the concerns about the development of bad practice were discussed and policy leads were aware of them, they were unable to identify any cases where this had happened and were clear their own policies did not advocate such practice. The discussions were not framed in deterministic tones, nor was there any labelling of their clients. The focus was on the impact of ACEs, rather than the number of ACEs.
• Policy leads acknowledged that responding to ACEs necessitated a range of interventions, from universal to specialist interventions.
• Policy leads were more aware and focussed on the implications of ACEs on mental health and well-being than on physical health. This suggests there might be a need to revisit the impact of ACEs on physical health in any future policy. Similarly, there appears to have been a greater focus on mitigating the impact of ACEs in policy, rather than on action to prevent them.
• Policy leads recognised Welsh Government policy needed to go beyond raising awareness of ACEs, to support action which prevented and mitigated their impact. This included supporting the development of tools and interventions which could help services and practitioners deal with ACEs. Many believed this should be a central role of the ACE Support Hub in the future.
• While policy leads were very positive of the contribution the ACE Support Hub had made in raising awareness of ACEs, there was broad agreement that  its role should now focus on preventative action and support for the development of trauma informed practice and services. They wanted to see its work focus on the identification and development of tools and resources to support this approach.

The Welsh Government’s policy leads had a similar view to external stakeholders of the importance of clarity about the purpose of the Welsh Government’s ACEs policy. Most felt it was important for the Welsh Government to restate its policy on ACEs with clear and consistent messaging. Some suggested there should be a shift in focus towards childhood adversity in a broader sense, rather than restricting policy to ACEs. They noted this would be similar to the approach being taken in Scotland. They saw the importance of developing a cross-government holistic approach to improve children’s life outcomes, with ACEs being part of it, alongside approaches to tackle other forms of childhood adversity. It was suggested on a number of occasions there was a need to develop a common set of outcomes which everyone should work towards and which could provide a means to measure improvement in outcomes. This would include any outcomes related to the decisions by services to move towards operating in a trauma informed way.

Some suggested the need to consider any future ACEs policy in the context of the COVID recovery plan and its impact on children’s cognitive, physical and emotional and social development, all of which has been impacted by COVID and COVID restrictions.

A number commented on how any future policy needed to support action outside of government. They suggested a need for more training for organisational structures to ensure the development of holistic approaches and greater engagement with strategic leads to enable strong leadership within their organisations.

Phase 1 of the review found there was a substantial and consistent body of evidence to support the ACEs framework. This included Public Health Wales’ studies into the prevalence and impact of ACEs in the Welsh adult population. The evidence demonstrated the strength of the association between childhood adversity and poorer physical and mental health and well-being across the life course. It showed ACEs can have a negative impact on child and adolescent brain development, which are associated with the adoption of a variety of health harming behaviours in adolescence that can impact on physical and mental health and well-being. It showed there is a graded relationship - the more ACEs you are exposed to, the greater the risk of experiencing poorer outcomes.

The evidence indicates the relationship between ACEs and outcomes is associative rather than deterministic, so even if someone experiences multiple ACEs, it does not necessarily mean they will experience poorer outcomes. While the evidence from the studies indicates ACEs are fairly common, with around half of the population likely to have experienced at least one ACE, poorer outcomes are less common. This is because individuals can experience adversity, and indeed the same adversity, in different ways due to their individual circumstances, personality traits and the sources of resilience and support available to them. Other factors which can influence outcomes include when the experience happened, how long it happened for and its intensity. The ACEs framework’s failure to take account of these factors is one of the sources of criticism levelled against it, as is its failure to take into account other sources of childhood adversity, including structural and social inequalities, which are also associated with poorer outcomes. 

For those who do go on to experience poorer outcomes as a result of ACEs, the evidence shows there can be significant personal and economic costs to individuals and their families. There can be significant social and economic costs to the community, public services and to society as a whole, because those who experience poorer outcomes are likely to place greater demand on these services. There is evidence to suggest many who have experienced ACEs will have been exposed to other adversities during childhood, including those related to structural and social inequalities and discrimination.

Phase 1 of the review sought to consider the views of those who express reservations about and objections to the ACEs framework. This includes reservations about our current understanding of ACEs, including the brain science; the strength of association between ACEs and outcomes; and the mechanisms which lead to poorer outcomes in some, but not in others. It included questions about our current understanding of how to prevent ACEs and mitigate their impact, including through the use of trauma informed approaches.

Criticisms levelled at the ACEs framework include its choice of, and restriction to, the ten ACEs and its failure to acknowledge the existence and impact of a wide range of other sources of adversity, as well as structural and social inequalities. There is criticism it treats all ten ACEs exactly the same and fails to consider when the ACE happened, its severity, frequency or duration, which has already been referred to above. It is criticised for failing to take into account the existence of any protective and mitigating factors, including sources of resilience and the importance of self-determination. However, one of the strongest areas for criticism is reserved for the ‘ACE score’ (the counting of number of ACEs experienced) to predict outcomes and who does and does not need support. The Welsh Government’s ACEs policy has always been clear that it does not condone or seek to encourage the practice of counting ACEs.

Phase 1 of the review explored what might be termed as more philosophical issues with ACEs, their use and potential for misuse. These included the use of language which can be viewed as focusing on deficits rather than strengths, which labels, blames and stigmatises people and has deterministic undertones. Others have questioned the oversimplification of the complex nature of the relationship between childhood adversity and trauma and life outcomes, its potential for pathologising and seeking to apply clinical solutions to social issues and placing the responsibility for solving them on parents. Some suggested the ACEs framework will result in ‘net widening’, with more people being inappropriately drawn into contact with statutory services.  

The review of existing evidence and literature found most concerns and criticisms were largely based on personal views, assumptions and conjecture, rather than much hard evidence of these problems occurring in practice in Wales. The concerns and criticisms were further explored with stakeholders during the Phase 2 discussion but, again, while there were anecdotal suggestions of the adoption of poor practices - like the application of the ACE score when dealing with individuals - there was little evidence of this or its existence in policy. This does, however, point to the importance of having a clear policy in such areas, supporting its consistent application and challenging any poor practices when they are identified.  

Phase 1 of the review finally considered how individual Welsh Government policies had responded to the central adoption of the ACEs framework. In its programme for government for this Assembly term, the Welsh Government included a number of commitments towards tackling ACEs. They included support for the development of ACE aware public services and helping to build children and young people’s resilience. Phase 1 indicated that during this Assembly term, a number of individual policy areas had reflected on the ACEs framework and evidence for ACEs in the development of their policies. Many had gone beyond this, by incorporating the need for the development of an awareness of ACEs, to focus on operating in a trauma informed way. The literature identified a number of instances in which the Welsh Government’s adoption of the ACEs framework had influenced UK government policy in non-devolved areas such as crime and justice, domestic abuse, family law and refugee and asylum seekers.

While the Welsh Government’s adoption of the ACEs framework is still relatively new, Phase 1 did identify evaluations by the ACE Support Hub, the Early Action Together Programme and Estyn which demonstrated it had already had a positive impact. However, further work to evaluate the effectiveness and impact of the Welsh Government’s ACEs policy is still required. This includes evaluating the impact of the decision by many services to become trauma informed. Phase 1 found there was little evidence yet available about the effectiveness or otherwise of such approaches. 

Phase 1 identified a number of questions to be asked of stakeholders during the phase 2 ‘discussion’. These included their views on the strength of the current evidence base for ACEs, the Welsh Government’s adoption of the ACEs framework and the current and possible future role of the ACE Support Hub for Wales. External consultants were appointed to lead the discussion with external stakeholders and officials from the Welsh Government’s Children and Families Division led a parallel discussion with Welsh Government policy leads. While those who took part in the discussion were not a representative sample of stakeholders, it did involve a range of key stakeholders, including those who questioned or expressed reservations about ACEs and the adoption of the ACEs framework to develop policy.

It is very clear from the discussion with both external and internal stakeholders that there is overwhelming support for the ACEs framework and the Welsh Government’s decision to prioritise action on ACEs. The majority were in favour of the Welsh Government continuing with its ACEs policy and expressed concern about any possible withdrawal from or significant change in its policy direction. This was not only because of their belief in and support for the ACEs framework, but because of the significant investment in time and resources they had made in implementing it at the direction of the Welsh Government.

Stakeholders referred to the thousands working in public services and third sector organisations who had received training in ACE awareness and trauma informed approaches. They noted the investment the Welsh Government had made in establishing an ACE Support Hub for Wales and the role the Hub had played, and continued to play, in embedding the ACEs framework in public services in Wales. Stakeholders did, however, express their support for the evolution of the ACEs policy. They supported the continuation of the ACE Support Hub, but noted the need for its role to change to allow services to progress from having an awareness and understanding of ACEs to operating in trauma informed and responsive ways.

The discussion demonstrated that external stakeholders and Welsh Government policy leads had a good knowledge and understanding of the ACEs evidence. Most were familiar with the key findings and could reference the science about the impact of ACEs on the child’s developing brain. They clearly understood the association between ACEs and physical and mental health outcomes across the life course, although it appeared the focus was more on mental health and well-being, than physical health. This might explain why there has been more of a focus on interventions, through the development of trauma informed services, than on preventative work. The discussions demonstrated there was good awareness of the positive impact of resilience and sources of resilience, in particular, the role of an always available adult. This would suggest the work which has been undertaken to support the development of ACE aware public services in Wales has been largely successful.

Many stakeholders expressed the view that the ACEs framework provided the evidence for what they felt they already knew about how childhood adversity can impact on outcomes in adulthood. It provided a model which could be used to explain this to others and make the case for the need to take action. They suggested the adoption of the ACEs framework by the Welsh Government had helped to foster a common understanding and language around childhood trauma and adversity, and provided a focus around which different policy areas and services could work together.

While some recognised there are limitations in some aspects of the current evidence base, few questioned the strength of the case for action. While some might not have fully appreciated the ACEs studies were epidemiological studies, they did understand the relationship between ACEs and outcomes was an association, rather than causal. They also understood ACEs were not deterministic and just because someone had ACEs, it did not mean they would experience poorer outcomes in later life.

This lack of understanding, by some, about the nature of the ACE studies was a concern for some stakeholders. They felt some did not understand the studies were focused on the impact of ACEs at a population level and that its findings could not be directly applied to individuals. Central to their concerns was the potential for the misuse of the ACE score. As noted above, any use of an ACE score to identify which individuals need of support, the type of support needed and establish intervention thresholds, is contrary to the Welsh Government’s ACEs policy. While some stakeholders cited anecdotal evidence of such practices, the review did not uncover many examples of this happening. However, this suggests the need to remain vigilant to the development of poor practice in Wales, and underlines the need for clear, consistent and regular messaging about what constitutes best practice.

The review showed there are some who question the validity of the ACEs framework. Although, they constitute a minority, especially in Wales, it is important to consider their views in the development of any future ACEs policy for Wales.

The area of evidence which stakeholders were concerned about was the evidence of what works in preventing ACEs and mitigating their impact. Most supported the adoption of trauma informed approaches and interventions, despite a lack of common understanding of what this actually means. Most stakeholders look to the Welsh Government to provide leadership in this area. 

Stakeholders acknowledged that just being aware of ACEs was unlikely to change people’s outcomes. They felt there was a need for the Welsh Government to take the lead in action to reduce ACEs and mitigate their impact and wanted to see its ACEs policy focus on identifying the interventions proven to make a positive difference, including those which promote trauma informed approaches. Stakeholders indicated they would also welcome a clear statement from the Welsh Government of its position on ACEs and the main purpose of its policy. They wished to see a policy which considered the relationship between ACEs and other forms of childhood adversity. They felt there was the need for a cross-government policy, with a clear, shared vision to support collaboration and challenge ‘silo working’ within and outside the Welsh Government.

The majority of stakeholders expressed support and appreciation for the work of the ACE Support Hub for Wales. While they supported its continuation, they felt it needed to change its focus from raising awareness to ‘what works’ in preventing ACEs and mitigating their impact.

While stakeholders were aware of the concerns which had been expressed about the language of ACEs, and had encountered this in their work, most supported the continued use of the term ACEs. Many were against making any wholesale change to the language of ACEs, fearing it would cause unnecessary confusion. They noted the language around ACEs had already begun to evolve, with services and practitioners now discussing the impact of childhood trauma and adversity, rather than ACEs. This was a natural evolution rather than an enforced change. As noted previously, many stakeholders called upon the Welsh Government to take a lead in developing common definitions for what is actually meant by terms like trauma informed.

There was no consistent view from stakeholders about the use of routine ACE enquiry. While some were fully supportive of its adoption, others were strongly opposed. The consensus seemed to be the Welsh Government should provide a clear lead. While there is a growing body of evidence of the potential positive impact of routine ACE enquiry, including from Wales, it is by no means conclusive that routine enquiry is the most appropriate way to have a conversation about childhood adversity. 

Many of the stakeholders, including those based outside Wales, felt Wales was seen as leading the way on tackling ACEs. This was particularly because of the work of Public Health Wales and its World Health Organisation Centre on Investment for Health and Well-being, the research it had undertaken on ACEs, and the Welsh Government’s early adoption of the ACEs framework. There were concerns if the Welsh Government didn’t continue with its ACEs policy, Wales would soon fall behind and lose its reputation as a leading nation.

Most stakeholders felt ACEs are likely to have increased as a result of the COVID-19 pandemic. They believed the Welsh Government should respond to this as part of its future ACEs policy and reflect it in its COVID recovery plan. They noted the increased exposure to ACEs and the social isolation associated with the lockdowns is likely to have negatively impacted children’s cognitive, physical and emotional and social development. COVID, and the lack of direct access to support services and financial hardships experienced by many during the lockdowns, is likely to have impacted on the child’s and family’s resilience and their ability to deal with adversity. Many noted there was evidence already emerging which indicated an increase in ACEs, with the rise in reporting of domestic violence often cited. There is evidence of increased referrals to services about child abuse and neglect and an increase in the numbers of children and young people seeking help for their mental well-being. An increase in exposure to adversity, at the same time as a reduction in access to support, has potentially created a perfect storm. This is likely to have long term implications for children’s health and well-being across their life course, something which is clearly demonstrated by the existing evidence on ACEs and which a clear and consistent Welsh Government policy on ACEs could help to prevent and mitigate.

The list of stakeholders who participated in the discussion with external stakeholders included representatives from:

• Education sector
• Flying Start
• Academics working in the field
• Public Health Wales
• NGOs
• Charities and the Third Sector
• Welsh Commissioners
• Criminal justice system
• Youth services
• Elected representatives
• Health sector
• Local Authorities
• The Children’s Rights Advisory
• Group (CRAG)
• The Learning Disability Forum
• The Children First Pioneers’ Network

The list of policy areas who took part in the discussion with internal stakeholders included:

• Child health
• Child poverty
• Children and families
• Crime and justice and community safety
• Education
• Equalities
• Family justice
• Housing and homelessness
• Looked after children
• Mental health
• Safeguarding and Advocacy
• Substance misuse
• Youth policy

[1] http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20%28E%29.pdf

[2] https://gov.wales/sites/default/files/publications/2017-08/taking-wales-forward.pdf

[3] https://gov.wales/sites/default/files/publications/2017-10/prosperity-for-all-the-national-strategy.pdf

[4] http://www.wales.nhs.uk/sitesplus/documents/888/ACE%20&%20Resilience%20Report%20(Eng_final2).pdf

[5] The Early Action Together Programme (EATP) piloted a multi-agency approach, with the four police forces, local authorities, third sector and PHW, collaborating to develop and deliver a public health approach to the policing of vulnerability by adopting an ACE informed approach. https://phw.nhs.wales/services-and-teams/early-action-together/#:~:text=The%20Early%20Action%20Together%20programme%20is%20supporting%20the,cycle%20of%20crime%20and%20ultimately%20improve%20their%20lives

[6] https://www.aceawarewales.com/timetobekind