2The evidence behind early intervention
5.This Chapter examines the current state of evidence relating adversity and trauma suffered in childhood to a range of problems in later life, as well as the effectiveness of measures that aim to prevent adverse childhood experiences or mitigate their linked negative outcomes.
Adverse childhood experiences
6.There is no universally agreed definition of an adverse childhood experience (ACE), but studies addressing the issue have mostly converged on a similar set of experiences falling under this term.8 A typical list of ACEs was used by Public Health Wales in a 2017 survey investigating the childhood experiences of approximately 2,500 Welsh adults. That survey used the following experiences:
- verbal abuse;
- physical abuse;
- sexual abuse;
- physical neglect;
- emotional neglect;
- parental separation;
- household mental illness;
- household domestic violence;
- household alcohol abuse;
- household drug abuse; and
- incarceration of a household member.9
The Public Health Wales survey reported that 50% of Welsh adults had experienced at least one ACE,10 a figure that closely matches survey results in England (47%).11 Comparable statistics have not been collected in Scotland or Northern Ireland, but a 2016 report by the Scottish Public Health Network estimated that prevalence in Scotland would be at least as high.12 The Children’s Commissioner’s Office estimates that at least 690,000 children aged 0–5 in England live in a household with an adult that has experienced domestic violence and abuse, substance misuse or mental health issues.13
7.A seminal 1998 study of over 9,000 adults in San Diego found a “strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults”.14 Similar studies have since repeatedly reported evidence of an increased prevalence of a range of problems in adulthood among those who suffered adversity in childhood.15 In the UK, surveys by Public Health Wales have reported a significantly increased prevalence of problems including health-harming behaviour, poor mental wellbeing and chronic disease among those who had suffered four or more adverse childhood experiences compared to those who had suffered none.16 Similar results have been found from large-scale surveys in England.17
8.Although most studies focus on a broad range of health-related outcomes, links have also been reported between ACE exposure and experience of wider social problems, such as reduced educational attainment, worklessness, diminished social mobility and lower socioeconomic status.18 Professor Mark Bellis, of Bangor University and Public Health Wales, told us that experiencing ACEs also significantly increased the risk of an individual’s involvement with the criminal justice system.19 However, the Early Intervention Foundation warned us that the extent to which ACEs were associated with many negative adult outcomes beyond physical or mental health problems was still uncertain.20
9.Several submissions to our inquiry pointed to methodological challenges in gathering evidence relating to the link between ACEs and wider social problems. For example, retrospective studies rely on adults recalling their childhood experiences, which the Academy of Medical Sciences told us “can be biased by their subsequent health and wellbeing”.21 Others noted that studies often used small samples, focused on specific populations or asked only one relevant group (e.g. children, parents or teachers) meaning that the case is only reported from one perspective.22 Nevertheless, the volume and diversity of supporting evidence appears to make clear the correlation between suffering adversity in childhood and experiencing further negative outcomes in later life.23 Indeed, Professor Sue White, of the University of Sheffield, told us that correlations between childhood adversity and clinical problems, such as mental health conditions, were “totally unsurprising”.24
Correlation versus causation
10.Experiencing childhood adversity is correlated only to a higher risk of experiencing certain problems in later life. Experiencing these problems is not guaranteed. Indeed, the English survey results referred to in paragraph 6 indicate that the majority of individuals, including those who have suffered four or more ACEs, do not engage in each of the correlated health-harming behaviours.25 Furthermore, all of these health-harming behaviours were also exhibited by some of those who had experienced no ACEs. Nevertheless, the prevalence of some conditions, such as low mental wellbeing, rises significantly with the number of ACEs that individuals have experienced.26
11.Although the correlation between suffering ACEs and negative consequences in later life seems widely accepted, this does not necessarily demonstrate causation. The British Psychological Society outlined one possible mechanism by which ACEs could lead to negative later outcomes:
Research indicates that experience of traumatic events in childhood can have a profound adverse impact on brain development leading to both physical and behavioural changes as the child tries to adapt to environmental stressors. If trauma occurs over a prolonged period, it can rupture the child’s internal stress system which then contributes to physical and mental health problems over the life course, making children more vulnerable to difficulties with emotional regulation from birth and is often linked to difficulties with cognition such as problems with attention and focus in early and later childhood.27
Professor Eamon McCrory, of University College London, described changes in brain structure and function resulting from maltreatment, and said that these were thought to reflect adaptations to adverse childhood environments that become ‘maladaptive’ in later life.28 However, he clarified that “we know very little about pure causation. Our understanding of the developmental mechanisms remains limited”.29 The Academy of Medical Sciences similarly told us that:
The degree to which negative outcomes are mediated through either continued adversity, or through the ACE being embedded within neuropsychological, immune, neuroendocrine or epigenetic change needs to be determined.30
12.The limited current understanding of causative mechanisms makes it difficult to eliminate all possible confounding factors underlying the apparent link between childhood adversity and negative outcomes in later life. In particular, socio-economic status was identified by a number of submissions as another factor that is also strongly correlated with negative outcomes,31 and some advocated including it as an ACE itself.32 Nevertheless, a range of studies that try to account for potential confounding factors still report correlation between ACEs and negative adult outcomes.33
The ‘ACE Framework’
13.The strongest criticism we heard regarding the uncertainty around causal pathways related to the validity of treating ACEs together, the practice of summing the number of ACEs experienced to determine an ACE ‘score’, and the misapplication of this ‘ACE framework’. Professor Rosalind Edwards of the University of Southampton warned us that from a methodological point of view, considering ACEs together was a “chaotic concept”, and that “conflating a lot of issues [means] that you cannot place much in the way of explanatory weight on them”.34 The NSPCC cautioned that ACE terminology could “encourage a reductionist view of very complex experiences”:
Within ‘ACE-speak’, one form of abuse is described simply as one ‘type’ of ACE. However, both in policy and practice, any form of abuse encompasses a very wide spectrum of abusive incidents and experiences, involving a very wide range of relationships between victims and perpetrators, occurring in many different contexts, of different durations, and whose impact on each individual is mediated by a range of factors.35
The Academy of Medical Sciences similarly noted that “it is not always clear where the line is drawn between normative stress experiences and ACEs”.36 The Early Intervention Foundation warned us that they had encountered the ACE framework being misused:
Limitations to this framework are not always fully understood by those trying to apply ACEs to their work with children. This had led to ACEs research being misapplied in practice, and we have encountered the ACE framework currently being used inappropriately. It should not be used to identify need and determine thresholds for prioritising who needs early intervention services.37
Professor Sue White also expressed her concern that some descriptions of ACEs could lead to a “self-fulfilling prophesy”, with people who are told that they are “damaged” having “lower expectations of themselves”, and their behaviour being blamed on past experiences.38 Kate Stanley of the NSPCC, however, rejected this view and told us:
That sounds a bit like psycho-babble to me, if I am honest. [Through the ACE framework, people who have suffered ACEs] are having a conversation about their lives and what is important to them. That opens up a conversation with services and then services are being commissioned in a way that responds to what people say they need.39
14.We did, however, also hear of some benefits of the ACE framework. The Association for Child and Adolescent Mental Health noted the frequent co-occurrence of different ACEs and suggested that measuring exposure to different ACEs cumulatively represented a “solution to this complexity”.40 Professor Bellis, of Bangor University and Public Health Wales, acknowledged that “by looking at [ACEs] together, you do not disentangle all of them”, but said that “for many people, that may be a more realistic way of looking at it, because these things do not often happen individually”.41 However, the real benefit of the ACE framework seemed to be in its use to raise awareness of the potential importance of early years experiences on outcomes throughout life, and to create a common language between early years practitioners working in different sectors.42 Professor McCrory told us that the framework was valuable provided it was used appropriately:
Within an epidemiological framework, I think that [the ACE model] can be incredibly helpful. I agree that taking it into a clinical context, as some kind of tool, or trying to have a conversation with individuals about ACE scores, is problematic.43
Donna Molloy, Director of Policy and Practice at the Early Intervention Foundation, added that the observed misapplication of the ACE framework meant that “clear messages about what it is for and what it is not for and how it might be used feels important”.44 The NSPCC similarly recommended that “any dissemination of the [ACE screening] tool should be accompanied by comprehensive staff training on its strengths and weakness. Specifically, staff must be alert to the fact that ACEs are not determinants of poor outcomes”.45
15.The evidence of the influence of early years experiences on brain development and outcomes throughout life is not predicated exclusively on the ACE framework and the observed correlation between experiencing ACEs and encountering negative outcomes in later life. Although neuroscience cannot yet say with certainty how ACEs might cause negative outcomes, there is strong evidence to suggest that brain development is affected by external factors, and that the early years are a critical period for development with consequences that can last throughout life.46 For example, Professor Edward Melhuish, of the University of Oxford, told us that the ‘Effective Pre-School, Primary and Secondary Education’ project (see footnote for description47) had demonstrated the long-term consequences of the early home learning environment,48 and that “for the vast majority of children, […] the end-of-school results are primarily predicted by the start-of-school results”, adding:
My work currently suggests that if you can get right language development and self-regulation, which is an aspect of socioemotional development, by the time children start school, almost everything else will fall into place.49
16.In addition to building the evidence base correlating childhood adversity to negative outcomes, Public Health Wales has also identified various ‘resilience factors’ that characterise those who tend not to encounter negative outcomes following exposure to ACEs.50 These include having a relationship with a trusted adult, participation in sport, or engagement with the local community. Professor McCrory made clear that such resilience related to the environment around a child:
It is not something that is in the child or individual; it is how the child is able to elicit help and use it from around them, but it is also about the social and physical resources around the child.51
Just like the evidence linking ACEs to negative outcomes, the relationship between resilience factors and improved outcomes demonstrates only correlation. Nevertheless, such findings suggest approaches that could be tried in order to improve the lifecourse of those who suffer adversity in childhood.
17.Research into adverse childhood experiences (ACEs) has usefully raised awareness of the importance of early years experiences on child development, and of the potential consequences associated with childhood adversity or trauma. The ACE framework helps to provide a common language for early years practitioners working in different sectors. However, the simplicity of this framework and the non-deterministic impact of ACEs mean that it should not be used to guide the support offered to specific individuals.
Early intervention
18.Within the context of childhood adversity and related outcomes, early intervention typically refers to measures intended to address problems such as mental or physical ill health, problematic behaviour or disengagement from the education system before their impacts require statutory intervention. The Government’s statutory guidance on child safeguarding refers to early intervention as “early help” and outlines the kinds of support that this term describes:
In addition to high quality support in universal services, specific local early help services will typically include family and parenting programmes, assistance with health issues, including mental health, responses to emerging thematic concerns in extra-familial contexts, and help for emerging problems relating to domestic abuse, drug or alcohol misuse by an adult or a child. Services may also focus on improving family functioning and building the family’s own capability to solve problems.52
This description hints at the variety of early intervention programmes that have been developed. The Early Intervention Foundation maintains an online guidebook detailing early intervention programmes and reviewing the evidence supporting their effectiveness.53 This currently contains 81 programmes, but Tom McBride, Director of Evidence at the Early Intervention Foundation, indicated that this was only a fraction of the total number of programmes being developed.54
19.Early intervention programmes are developed and delivered based on the premise that intervening earlier is better.55 The prevention of ACEs is justified simply by the aim to minimise children’s exposure to the negative experiences they encompass. However, the evidence base around ACEs, resilience factors and negative outcomes in later life suggests that resources spent on addressing issues such as physical and mental health or criminal behaviour would be well-targeted at the earliest opportunities for intervention. In fact, Professor Feinstein told us that the strongest evidence for the benefit of early intervention came not from scientific research into childhood adversity, but from evaluating the real-world impacts of early intervention programmes:
I do not come at this as somebody who thinks the evidence base on early childhood experiences is altogether the relevant evidence base. There is a lot of evidence in psychology and economics and a certain amount in neuroscience, although not at all necessary to the case for early intervention. There is a lot of evidence in the literature on programme evaluation and what is known when people try programmes, test them and they learn and adapt.56
Evidence for early intervention
20.Of the 118 programmes assessed for the Early Intervention Foundation’s Guidebook:
- six were judged to have strong evidence of long-term positive impact;
- 39 had evidence of a short-term positive impact from at least one rigorous evaluation;
- 36 were considered to not yet have demonstrated any evidence of achieving positive outcomes; and
- none had been found to be demonstrably ineffective by “at least one rigorously conducted study”.57
Some studies of early intervention programmes have, however, found little evidence of impact,58 and Cochrane reviews of different parent support and early intervention programmes have reported mixed results for effectiveness.59 That said, some studies reporting little impact have been criticised for evaluating the wrong outcomes.60 Dr Caroline White, Head of the Children and Parents Service in Manchester (who acted as our Specialist Adviser for this inquiry), also argued that evidence of ineffective interventions could result from poor implementation rather than an inherent failing of the intervention itself.61 In addition to this range of results, many programmes are simply not evaluated at all.62
21.There is sometimes criticism that the evidence for early intervention comes mostly from randomised controlled trials of specific programmes, rather than from an assessment of the real-world impact on the communities where they are delivered. Donna Molloy, Director of Policy and Practice at the Early Intervention Foundation, noted that “it is much easier to evaluate a specific programme or intervention than to think about the system as a whole and all the different components of it and which bits might be performing well or otherwise”, thus suggesting a possible reason for this lack of ‘real-world’ evidence.63 Alison Michalska, the then President of the Association of Directors of Children’s Services, also outlined the difficulty for local authorities in measuring the wider impact of early intervention:
We all believe in its efficacy instinctively but if we are using it as a tool to manage demand on statutory children’s social care services it could be perceived as failing—given the rising number of referrals, child protection plans and children in care. Or (and this is my preferred narrative) are we, through early help and early interventions, identifying children who need the protection of statutory services earlier, and as such, protecting them from further harm and making long term plans for these children to thrive?64
22.Despite the difficulty in measuring the real-world impact of early intervention, Martin Pratt, Chair of the Association of London Directors of Children’s Services, told us that London boroughs had observed early intervention programmes to be effective:
The key indicator for us is the proportion of families we become aware of who receive early help and who, a year later, are still free from further state intervention. The figure at the end of March this year [2018] is that 83% of families who were identified early and went into an intensive early help programme do not have a social work or child protection intervention a year later.65
Dr Caroline White told us that evidence collected in Manchester also demonstrated the effectiveness of early intervention (see Box 1, paragraph 109).66 In 2011, a Government-commissioned study of five parenting programmes delivered across 47 local authorities in England found that the programmes improved self-reported parental wellbeing, parenting and child behaviour.67 Pulling together disparate study results, Professor Feinstein summarised the current evidence base for early intervention:
It always comes back to the question: do we know [if early intervention] works? We know that if you deliver high-quality services to people who need them—the right features of quality, delivered at the right time—they can be transformative in most circumstances […] the question is not whether it works; the question is when it works and how to make it work more.68
23.In addition to the impact on child and adult outcomes, proponents of early intervention frequently note its ability to save costs in the long-run, by avoiding expensive statutory interventions and lost productivity. In 2016, the Early Intervention Foundation estimated that the national cost of ‘late intervention’ (the acute, statutory and essential benefits and services that are required when children and young people experience significant difficulties in life that might have been prevented) was £16.6bn.69 They noted that this “does not capture longer‐term cumulative costs which will be considerably larger; it also does not capture wider cost to individuals and society”.70 The cost derived mostly from expenditure on children’s social care, crime and anti-social behaviour and youth economic inactivity, and fell largely on local government, the NHS, the Department for Work and Pensions and the police and criminal justice system. The Early Intervention Foundation argued that although it did not think “the demand for late intervention spend can ever be brought down to zero, nor should it be”,71 this estimated cost of late intervention nevertheless “clearly represents a significant avoidable burden that could be better spent, and even modest reductions would equate to large savings”.72 Professor Feinstein told us that it might ultimately be reasonable to expect to save 30 to 40% of this ‘late intervention’ expenditure, and set saving 10% as a realistic immediate target.73
24.Associate Professor David McDaid, of the London School of Economics and Political Science, told us that evaluation of a variety of programmes provided strong evidence of the cost-effectiveness of early intervention.74 Professor Melhuish similarly noted that, despite variation in the precise cost-benefit, studies of the economic impact of early intervention consistently found positive results.75
25.There is now a body of evidence that clearly demonstrates a correlation between adversity suffered during childhood and an increased prevalence of health and social problems in later life. Despite a variety of proposed explanations for this correlation, the causal pathways linking childhood adversity or trauma to subsequent problems are less certain. Nevertheless, when delivered effectively, there is strong evidence that early intervention can dramatically improve people’s lives and reduce long-term costs to the Government. The Government should ensure that it is making the most of the opportunity for early intervention to effectively and cost-effectively address childhood adversity and trauma, and the long-term problems associated with such experiences.
Research priorities
26.Despite the encouraging results regarding the efficacy and cost-effectiveness of early intervention, we heard some recognition of the evidence that remains to be gathered. The Early Intervention Foundation told us that, although reviews of the available evidence “highlight the crucial role early intervention can play in preventing childhood adversities and in helping children recover from the effects of early trauma […] the evidence base for early intervention in the UK is still at an early stage”.76 They added that “a sustained and substantive change [to child outcomes] will require an ambitious and long-term research strategy”.77 A literature review commissioned by the Big Lottery Fund similarly commented that although cost-benefit studies “appear to make a compelling case for investing in early childhood”, the “economic evidence base from published reviews is not strong”.78 The importance of further research was stressed by many79—but not all80—submissions that we received. Particular research priorities that were frequently identified included:
- establishing the extent of the causality between ACEs and negative outcomes later in life, and the mechanisms through which this occurs;
- determining the relative risks of different ACEs, their severity and duration, and the stage of development at which they occur;
- the development and validation of preventative and remedial interventions, in particular regarding their long-term impact; and
- the development of methods for reliably identifying those who would benefit from early intervention.81
Professor McCrory underlined the importance of developing a better understanding of the fundamental science involved:
If we do not understand the mechanisms by which disorders unfold, we are in a very limited place to develop preventive models of health.82
Professor Feinstein nevertheless stressed that enough was known to start delivering early intervention, and testing and evaluating innovative approaches to such practice:
We cannot say that every bit of early intervention will work, but we know the principles—and if we can innovate and support innovation, and testing and learning, we will make this all much better.83
Jackie Doyle-Price MP, Parliamentary Under-Secretary of State for Mental Health and Inequalities at the Department of Health and Social Care,84 acknowledged that waiting for the evidence base to be fully established could delay successful programmes from being developed and delivered:
The biggest challenge in all this is to be sufficiently fleet of foot to make a real difference. You see a real success where there is really strong local leadership that has just grabbed something […] The outcomes are there to be proven and demonstrated.85
27.The Academy of Medical Sciences told us that “funding bodies such as the Research Councils appear to recognise that this field requires additional funding”, but commented on the “need for better co-ordination between research about ACEs and associated outcomes including mechanisms and research on the effectiveness of interventions, which is separately funded”.86 The Association for Child and Adolescent Mental Health similarly told us that “there is no sense of a national strategy in this area”, with the identification of research priorities appearing to be “ad hoc and based on individual funding bodies and their own priorities”.87 They advocated establishing a British equivalent to the Harvard Center on Child Development to “bring together evidence from social work practice to clinical psychology to neuroscience and paediatrics”.88 However, Professor Feinstein told us that he was “not at all convinced that a multidisciplinary centre on the American model is any kind of answer to the British problem”.89
28.Multiple research organisations flagged the use that could be made of administrative data held by the Government for investigating the impacts of ACEs and early intervention,90 if such data were more easily accessible and if different sets of data could more easily be linked.91 CLOSER, a consortium managing various UK-based longitudinal studies, told us:
Gaps in the evidence base [concerning ACEs and later outcomes] are, in part, a result of not being able to link longitudinal survey data to administrative records to provide a more complete picture of participants’ life stories and to better understand how different aspects of people’s lives interrelate.92
Tom McBride, Director of Evidence at the Early Intervention Foundation, agreed that “there is a lot of opportunity” in improved data access and underlined the Government’s responsibility in enabling this research to be carried out, citing records from the criminal justice, benefits, tax and education systems as examples of data that “could facilitate much deeper and higher-quality research in this space”.93
29.Despite the importance of evaluating early intervention programmes being made clear during our inquiry (see paragraphs 26 and 83 to 88), to ensure that they are delivering the intended impacts and to inform improvements, Professor Melhuish, of Oxford University, argued that funding was currently too heavily skewed towards evaluation over innovation and development and complained that “this is a really big fault in current Government funding”.94 Jen Lexmond, CEO of EasyPeasy, agreed, noting that her company had received four times as much funding to support evaluation as it had for development.95 She advised that she would expect the ratio to be closer to 10%. Despite arguing that funding was tight even for evaluation,96 the Early Intervention Foundation highlighted the continuing need for new interventions to be developed, noting that it had so far found no interventions which demonstrated effectiveness in addressing sexual abuse, parental substance misuse or parental incarceration and crime.97
30.Although our inquiry has focused on opportunities to intervene early to address ACEs, we also heard of approaches that could be taken to support adults who had experienced ACEs in their childhood. In particular, we heard advocates of ‘routine enquiry’, who argued that support services—typically in health and social care—could benefit their service users by routinely asking at the initial point of contact if they had suffered ACEs in their childhood.98 This was presented as a key part of providing ‘trauma-informed’ care, allowing professionals to tailor their support to the person’s prior experiences, and potentially to help service users better understand how their experiences had impacted them. Dr Warren Larkin told us that without adopting a policy of routine enquiry, practitioners rarely asked about such experiences and it could take nine to 16 years of contact for disclosure.99 He noted the importance of training practitioners to be able to ask about ACEs confidently and respond appropriately:
Survivors of [adverse childhood] experiences can often be reluctant to disclose voluntarily, due in part to feelings of shame, guilt and anxiety about their experiences and the act or consequences of disclosure. However, survivors have suggested that these issues can either be exacerbated or alleviated by the responses of the person listening to their disclosure. Furthermore, health and social care practitioners have described an unwillingness or discomfort with the idea of having to ask people about childhood adversity and trauma.100
It is also important that services asking about childhood adversity can provide or refer people to the appropriate support following enquiry.101 Although an initial study in the USA reported that introducing routine enquiry about ACEs into health appraisals undertaken for induction into private healthcare reduced visits to doctors’ offices and emergency departments the following year,102 evaluation of the effect on patient outcomes in the UK has been mostly restricted to proof-of-concept studies.103 Nevertheless, routine enquiry is now starting to be introduced and tested around the UK, with NHS Scotland notably exploring routine enquiry as part of its strategy for tackling ACEs.104
31.Important research questions regarding childhood adversity and early intervention remain. Progress on this front would benefit from a more co-ordinated approach across different academic fields, as well as greater access to relevant administrative data held by the Government. As it starts working towards its goal of improved interdisciplinary collaboration, UK Research and Innovation should co-ordinate research into child development and early intervention methods for addressing childhood adversity, across different academic disciplines. Particular focus should be on developing interventions to address adverse childhood experiences for which no effective intervention has been demonstrated, including sexual abuse, parental substance misuse or parental incarceration and crime.
32.Further, we recommend that the Government should ensure that academic researchers can access Government administrative data relevant to childhood adversity, long-term outcomes and the impact of early intervention, while ensuring appropriate privacy and safeguarding mechanisms are in place. UKRI should consult the relevant academic community to determine which data would be beneficial, and work with Government departments to ensure researchers can access that data as appropriate.
8 Hughes et al., ‘The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis’, Lancet Public Health vol 2 (2017)
9 Public Health Wales, ‘Sources of resilience and their moderating relationships with harms from adverse childhood experiences’ (2018)
10 Public Health Wales, ‘Sources of resilience and their moderating relationships with harms from adverse childhood experiences’ (2018)
11 Bellis et al., ‘National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England’, BMC Medicine vol 12 (2014)
12 Scottish Public Health Network, ‘Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland’ (2016), p16
13 Children’s Commissioner, ‘Estimating the prevalence of the ‘toxic trio’’ (2018)
14 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)
15 For example, see Hughes et al., ‘The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis’, Lancet Public Health vol 2 (2017)
16 Public Health Wales, ‘The Welsh Adverse Childhood Experiences (ACE) Study’ (2016)
17 Hughes et al., ‘National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England’, BMC Medicine vol 12 (2014)
19 Q2
22 For example the Academy of Medical Sciences (EYI0028), the International Centre for Lifecourse Studies in Society and Health (EYI0043) or the University of Bristol (EYI0086)
23 The Academy of Medical Sciences summarised that “there is strong evidence linking adverse childhood experiences (ACEs) and poor outcomes in adulthood both in terms of mental and physical health”—Academy of Medical Sciences (EYI0028)
24 Q16
25 Bellis et al., ‘National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England’, BMC Medicine vol 12 (2014)
26 For example, low mental wellbeing affects 14% of adults who have experienced 0 ACES, 16% of those who have experienced 1 ACE, 23% of those who have experienced 2–3 ACEs and 41% of those who have experienced 4 or more ACEs (Public Health Wales, ‘Adverse Childhood Experiences and their association with Mental Well-being in the Welsh adult population’, 2016); 2.0% of adults who have experienced 0 ACES, 3.6% of those who have experienced 1 ACE, 8.7% of those who have experienced 2–3 ACEs and 13.9% of those who have experienced 4 or more ACEs have perpetrated violence (Bellis et al., ‘National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England’, BMC Medicine vol 12 2014)
28 Q27
29 Q27
31 For example, CLOSER (EYI0020), the Royal College of Paediatrics and Child Health (EYI0054) and Emerita Professor Hilary Rose and Emeritus Professor Steven Rose (EYI0095)
33 For example, Public Health Wales, ‘Sources of resilience and their moderating relationships with harms from adverse childhood experiences’ (2018)
34 Q10
38 Qq20 and 36
39 Q56
41 Q9
42 For example, see Q9, Q14, Q51 and Q188
43 Q14
44 Q189
46 For example, see Save the Children, ‘Lighting up young brains’ (2016); Harvard Center on the Developing Child, ‘The Science of Early Childhood Development’ (2007)
47 The Effective Pre-School, Primary and Secondary Education project monitored the development of more than 3,000 children from the start of pre-school through to their post-16 education, training or employment choices in order to study the effectiveness of early years education.
48 Q131; Department for Education, ‘Students’ educational and developmental outcomes at age 16: Effective Pre-school, Primary and Secondary Education (EPPSE 3–16) Project’ (2014)
49 Qq111 and 128
50 Public Health Wales, ‘Sources of resilience and their moderating relationships with harms from adverse childhood experiences’ (2018)
51 Q37
52 HM Government, ‘Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children’ (2018), para 12
53 ‘Early Intervention Foundation Guidebook’, Early Intervention Foundation, accessed 2 May 2018
54 Q201
55 Professor Feinstein clarified that “it should be ‘early’ as in upstream of crossing the thresholds, not ‘early’ as in early in life necessarily, because early in life it can be very hard to identify accurately what the actual needs are, so there is a danger of very inefficient forms of identification”—Q62
56 Q63
57 ‘Early Intervention Foundation Guidebook’, Early Intervention Foundation, accessed 25 July 2018
58 For example, see Robling et al., ‘Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial’, The Lancet vol 387, pp 146–155 (2016); Marryat et al., ‘Parenting Support Framework Evaluation’ (2014); or MacMillan et al., ‘Interventions to prevent child maltreatment and associated impairment’, The Lancet vol 373, pp 250–266 (2009)
59 For example, Barlow et al., ‘Group-based parent training programmes for improving emotional and behavioural adjustment in young children (Review)’, Cochrane Database of Systematic Reviews (2016); Furlong et al., ‘Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Review)’, Cochrane Library (2012)
60 For example, Jason Strelitz, Assistant Director Public Health, London Boroughs of Camden and Islington, ‘The FNP evaluation: Inconvenient truth or a bump in the road?’ (2015), accessed 3 May 2018
61 Q226
62 Q180
63 Q193
64 Alison Michalska, President of the Association of Directors of Children’s Services, Early Intervention Foundation National Conference keynote speech, 11 May 2017 (accessed 29 May 2018)
65 Q222
66 Q218; see also CAPS annual reports
67 Department for Education, ‘Parenting Early Intervention Programme Evaluation’ (2011)
68 Q63
69 Early Intervention Foundation, ‘The Cost of Late Intervention: EIF Analysis 2016’ (2016)
70 Early Intervention Foundation, ‘The Cost of Late Intervention: EIF Analysis 2016’ (2016), p7
71 Early Intervention Foundation, ‘The Cost of Late Intervention: EIF Analysis 2016’ (2016), p5
73 Q93
74 Q76
75 Q111
78 Bonin et al., PSSRU, London School of Economics and Political Science (EYI0081), Big Lottery Fund (EYI0091); Bonin et al., ‘ What Pays? A ‘Preventonomics’ Study (2014)
79 For example, Newcastle University (EYI0007), the Academy of Medical Sciences (EYI0028) and the Association for Child and Adolescent Mental Health (EYI0070)
80 The Children and Parents Service in Manchester told us that “we already know what works in early intervention so it would benefit its implementation by ceasing to expend energy and resource looking for the next new thing or ‘home grown’ interventions and instead invest existing resources into what works” (Children and Parents Service (CAPS) Early Intervention (EYI0004))
81 For example, see the MRC/CSO Social and Public Health Sciences Unit (EYI0021), the Academy of Medical Sciences (EYI0028), the Association of Directors of Public Health (EYI0031), Public Health England (EYI0033), Barnardo’s (EYI0037), the Early Intervention Foundation (EYI0061), the Association for Child and Adolescent Mental Health (EYI0070), the Centre for Longitudinal Studies, University College London (EYI0075) and Professor Peter Fonagy (EYI0097)
82 Q32
83 Q82
84 Since giving evidence to our inquiry, the Minister has had her portfolio expanded and is now the Parliamentary Under Secretary of State for Mental Health, Inequalities and Suicide Prevention. Throughout this Report, we refer to her Ministerial title as it was at the time she gave oral evidence to our inquiry.
85 Q419
89 Q97
90 For example, the Children Looked After registry, the National Pupil Database, Hospital Episode Statistics, HMRC employment data, Ministry of Justice police records, benefits data from the Department for Work and Pensions and Local Authority Management Information Systems data
91 For example, CLOSER (EYI0020), the Institute for Social and Economic Research (EYI0055) and the Centre for Longitudinal Studies, University College London (EYI0075)
93 Q209
94 Q170
96 Qq195–196
98 For example, YoungMinds (EYI0013), Dr Warren Larkin (EYI0015), Greater Manchester Combined Authority (EYI0047) and Mersey Care NHS Foundation Trust (EYI0074)
102 Dr Vincent Felitti et al., ‘The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare’, in ‘The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease’, Cambridge University Press (2009)
103 For example, Public Health Wales and Lancashire Care NHS Foundation Trust, ‘Routine enquiry for history of adverse childhood experiences (ACEs) in the adult patient population in a general practice setting: A pathfinder study’ (2018)
104 Scottish Public Health Network, ‘Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland’ (2016)
Published: 14 November 2018