The ACE Agenda

ACE stands for Adverse Childhood Experience and you are going to hear much more about it over the coming years. While there has been surprisingly little work on ACE so far in in the UK, the US Centre for Disease Control (CDC) and Kaiser Permanente have been studying ACE over the past 14 years and come to some remarkable conclusions.  ACE may radically change the way we think about public investment for the prevention of both chronic disease and crime prevention.

The list of Adverse Childhood Experiences has been compiled from evidence based research analysis of factors known to cause ‘toxic stress’ in children which affects their cognitive and emotional development. This in turn affects their lifestyles and behaviour in adult life and ultimately their risk of both early death and crime and anti-social behaviour. The list includes having a parent with a significant mental health, alcohol or drugs problem, having a member of immediate family in prison, exposure to domestic violence in the household etc. The diagram below shows how ACE studies have modelled the ‘causal chain’ from ACE to preventable mortality.

Studies in America, Canada and Philippines have shown that as the number of exposures to ACEs increase, the more likely a person is to experience risky lifestyle behaviours, including smoking, severe obesity, physical inactivity, depressed mood and suicide attempts, anti- social behaviour and crime.  Furthermore, as the number of categories of ACEs increase, the presence of adult diseases, such as ischemic heart disease, cancer, chronic lung disease, skeletal fractures and liver diseases all increase – in ways that might be predicted and modelled.

For instance, US studies have found that four or more adverse childhood exposures significantly increase the odds of a person:

• developing cancer (by nearly two times);
• being a current smoker (just over two times);
• having sexually transmitted infections (by two and a half times);
• using illicit drugs (by nearly 5 times increased risk);
• being an alcoholic (over seven times increased risk);
• attempting suicide (over 12 times increased risk).

According to a CDC study released earlier this year, just one year of confirmed cases of child maltreatment in the US cost $124 billion over the lifetime of the traumatized children. The researchers based their calculations on only confirmed cases of physical, sexual and verbal abuse and neglect, which child maltreatment experts say is a small percentage of what actually occurs.

The breakdown per child is:

• $32,648 in childhood health care costs
• $10,530 in adult medical costs
• $144,360 in productivity losses
• $7,728 in child welfare costs
• $6,747 in criminal justice costs
• $7,999 in special education costs

ACE studies offer a new way of thinking about prevention of chronic disease and the likelihood of engaging in crime and anti-social behaviour. Knowing the ACE risk in a given population or individual offers a compelling moral and cost efficient rationale for adopting a more assertive and universal preventative approach to childhood abuse and neglect. This has major implications for healthcare professionals and the criminal justice system. Patients accessing healthcare for instance could be routinely screened for ACEs; childhood trauma history may be relevant to serious chronic illness and more effective and appropriate approaches to early intervention and treatment might be developed.  Citizens might know their ACE score and commit to not passing it onto their children.

The evidence suggests that early screening of ACEs and increased investment in early intervention services might provide an excellent return on investment across a broad spectrum of the population. With strong UK population based predictive analytic data, new models of early investment for the prevention of chronic disease and crime reduction might be possible – jointly funded by health, education and the criminal justice system who would be shared beneficiaries of any future ‘preventive dividend’.

Most importantly, with more UK research data, early intervention in ACE risk may allow us to radically improve the lives of children and the life expectancy of the adults they will become.