The impact of adverse experiences in the home on the health of children and young people, and inequalities in prevalence and effects
Adverse childhood experiences (ACEs) are situations which lead to an elevated risk of children and young people experiencing damaging impacts on health, or other social outcomes, across the life course. This report addresses the issue for those under the age of 18 who: are abused or neglected; live in households where domestic violence, drug and alcohol misuse, mental ill health, criminality, or separation are present; or who live in care. In many cases multiple ACEs are experienced simultaneously.
Approximately half of the English population have experienced one or more ACEs, although this varies according to the type of ACE. For example, in one study, 12% reported witnessing domestic violence before the age of 18, but only 3.9% parental drug misuse. Experience of adversity tends to cluster (several ACEs co-occurring) – and those who experience four or more adversities are at a significantly increased risk of poor health outcomes across the life course compared to those with no ACEs. It is also probable that some ACEs are more likely to have negative impacts than others, although due to the fact that they are often experienced (and measured) simultaneously, this is hard to ascertain.
It is not always the case that children will be harmed by exposure to ACEs: for instance, sometimes parental separation can be protective of children’s wellbeing (for example, where domestic violence is present). However, evidence from England and elsewhere shows that children and young people who are exposed to ACEs are at a greater risk of death or injury before reaching adulthood, and of premature mortality later on in life. For example, women who were exposed to two or more ACEs before the age of 18 have an 80% higher risk of dying by age of 50 compared with those who were not exposed to any ACEs. Not only are those who are exposed to ACEs more likely to die at a younger age than those who are not, but they are also more likely to experience a range of illnesses – including cancer, heart disease, lung disease, liver disease, stroke, hypertension, diabetes, asthma and arthritis . ACEs also increase the risk of mental ill health: the World Health Organisation estimates that 30% of adult mental illness in 21 countries could be attributed to ACEs.
The potential ‘pathways’ by which ACEs could impact on health outcomes include through an increase in health harming behaviours. For example, those who experienced four or more adverse experiences during childhood have an increased odds ratio of 11 for using heroin or crack cocaine a negative impact on educational, employment and income outcomes; and an impact on genetic, epigenetic and neurobiological functioning, which also impacts on health across the life course.
There is a clear inequalities dimension to ACEs. While all ACEs are present across society, inequalities in wealth, disadvantage and the existence of poverty impact on the chances of experiencing ACE. Children growing up in disadvantaged areas, in poverty, and those of a lower socioeconomic status are more likely to be exposed to ACEs compared to their more advantaged peers – and more likely to experience ‘clustering’ (co-occurring) of ACEs). Aside from these socioeconomic factors, there is a range of other risk factors for ACE, including poor and harmful parenting approaches and the relative stress under which families live. These risk factors are also universal but are again more likely to occur lower down the social gradient. Due to inequalities in the prevalence of ACEs, and the observed negative health impacts of ACEs, it is likely that ACEs are currently contributing to health inequalities. There is also evidence that ACEs are ‘transmitted’ across generations – so that the children of parents who experienced ACEs in their own childhood are also more likely to experience ACEs (14-16). This perpetuates inequalities in health across generations.
Taking action on the causes, prevalence and impacts of ACEs is therefore necessary in order to improve health, reduce inequalities within generations, prevent the transmission of disadvantage and inequality across generations and improve the quality of children, young people and adult’s lives. One study suggested that 12% of binge drinking, 14% of poor diet, 23% of smoking, 52% of violence perpetration, 59% of heroin and crack cocaine use and 38% of unintended teenage pregnancy prevalence nationally could be attributed to ACE experience below the age of 18. Reducing these rates would improve health and also save money.
The cost of child maltreatment alone has been estimated to total £735m a year ) and reducing the health impacts of ACE could decrease pressure on the NHS and other local support services. In 2009 the costs of domestic violence in the UK were estimated at £1.9bn in terms of lost economic output, £10bn in human and emotional costs and approximately £3.1bn to government funded services. The cost of children in care is £2.9bn, of which an estimated half is spent on abused children.