The ACE Reckoning

In 1998, Vincent Felitti and colleagues at Kaiser Permanente published the results of a study that would eventually change how the medical establishment thought about disease, behaviour, and the long shadow of childhood experience.

They surveyed 9,508 adults who had completed a standardised medical evaluation at a large health maintenance organisation. The questionnaire asked about seven categories of adverse childhood experience: psychological, physical, or sexual abuse; violence against a mother; and living with household members who were substance abusers, mentally ill, suicidal, or imprisoned.

What they found was a graded relationship, a dose-response, between the number of categories of adverse childhood experience and almost every measure of adult health risk they examined.

What Felitti found

Persons who had experienced four or more categories of adverse childhood experience, compared to those who had experienced none, had four to twelve times the health risks for alcoholism, drug abuse, depression, and suicide attempt. They had two to four times the risk for smoking, poor self-rated health, and sexually transmitted disease.

The number of adverse childhood experience categories showed a graded relationship to the presence of adult diseases including ischaemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.

State-enforced separation from a primary caregiver is not listed as one of Felitti's seven original categories. But it meets every criterion for inclusion. It is an adverse experience. It occurs in childhood. It involves household dysfunction. And its effects on neurodevelopment, stress reactivity, and long-term health are documented in the Bucharest data, the US border separation research, and the JCHR inquiry testimony.

What the Lancet meta-analysis confirmed

Hughes, Bellis and colleagues published a systematic review and meta-analysis in The Lancet Public Health in 2017, drawing on data from 37 studies. They found that individuals who had experienced four or more adverse childhood experiences were significantly more likely to have multiple health risk behaviours and poor health outcomes across the life course, including mental ill health, problematic alcohol use, violence, and cancer.

The dose-response relationship that Felitti identified in 1998 held across multiple countries, multiple methodologies, and multiple decades of subsequent research. The evidence base is not fragile. It is one of the most replicated findings in public health research.

What the Bellis trust study adds

In 2024, Bellis, Hughes, Ford and colleagues at Public Health Wales and Liverpool John Moores University published a national cross-sectional survey of 1,880 adults in Wales, measuring the relationship between adverse childhood experience exposure and trust in institutions, professionals, and information sources.

The findings have a direct bearing on what this series has documented about family court proceedings.

Individuals with four or more adverse childhood experiences were over three times more likely to have low trust in police than those with no adverse childhood experiences. They were nearly three times more likely to have low trust in health services and social services. Low trust in government was the highest of all, rising from 48% in those with no adverse childhood experiences to 74% in those with four or more.

The researchers note a painful circularity. Those with a history of adverse childhood experiences are most likely to need health, social, and legal services. They are also least likely to trust the advice and information those services provide. The institutions most responsible for causing or failing to prevent the harm are also the institutions those individuals are least able to trust when seeking help.

Bellis and colleagues note that positive relationships with caregivers in childhood are related to stronger attachments and help develop the ability to trust others. When children have been hurt or neglected by caregivers, their ability to trust may be diminished along with their ability to form attachment bonds, even subsequently with their own children. The intergenerational cycle begins precisely at the point Bowlby identified: in the earliest relational environment, in the presence or absence of a consistent caregiver, in the protest-despair-detachment sequence that state-enforced separation reliably produces.

The institutional irony

This is the closing argument of the series.

The institutions that cite ACE research in their own policy documents, local authorities, children's services, family courts, NHS trusts, are the same institutions that five independent reports have documented as having caused the harm the ACE framework describes.

This is not speculation. It is traceable.

The Ministry of Justice Harm Panel documented systematic minimisation of abuse in private law proceedings. The Domestic Abuse Commissioner confirmed it had not changed. The IICSA documented institutional self-protection across multiple sectors. Baroness Casey named it. Parliament named it. The UN named it.

And Felitti's dose-response relationship means that every child who experiences enforced separation from a fit, loving parent, every child who goes through the protest phase, the despair phase, the detachment phase, is accumulating ACEs. Each one shifts their probability of poor health outcomes upward. Each one increases the likelihood that they will grow into an adult who does not trust the institutions most responsible for what happened to them.

What StoryQuest proved inside that

The methodology that is now in nine schools, validated by Parliament and the British Psychological Society, presented to UNICEF, and achieving 100% engagement including with children the system has already written off, was built inside the setting this research describes.

One hour a week on FaceTime. No academic framework. No institutional support. A mother whose protective concern had been reframed as pathology, building something extraordinary in the space between what was taken and what remained.

The Bellis research shows that the most important communicators for people with high adverse childhood experience counts are not institutions. They are trusted individuals, people who have demonstrated that they hear what is said and do not use it against the person saying it.

That is what StoryQuest does for children. That is what Kate Markland does for the mothers who recognise themselves in this research. The methodology was built inside the problem it solves. The evidence has confirmed it.

Source references

Felitti, V. et al (1998) 'Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The ACE Study.' American Journal of Preventive Medicine, 14(4), 245–258.

Hughes, K., Bellis, M.A. et al (2017) 'The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.' The Lancet Public Health, 2(8), e356–66.

Bellis, M.A., Hughes, K., Ford, K. et al (2024) 'Associations between adverse childhood experiences and trust in health and other information.' BMJ Public Health, 2: e000868.

Hampton, K. et al (2021) 'The psychological effects of forced family separation on asylum-seeking children and parents at the US-Mexico border.' PLOS ONE.