{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T20:46:35Z","timestamp":1783197995901,"version":"3.54.6"},"reference-count":29,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2023,8,23]],"date-time":"2023-08-23T00:00:00Z","timestamp":1692748800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Health Care Research Wales","award":["MR-VO49879\/1"],"award-info":[{"award-number":["MR-VO49879\/1"]}]},{"name":"UK Prevention Research Partnership","award":["MR-VO49879\/1"],"award-info":[{"award-number":["MR-VO49879\/1"]}]},{"name":"Public Health Wales","award":["MR-VO49879\/1"],"award-info":[{"award-number":["MR-VO49879\/1"]}]},{"name":"National Centre for Population Health and Wellbeing Research","award":["MR-VO49879\/1"],"award-info":[{"award-number":["MR-VO49879\/1"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Adverse childhood experiences (ACEs) encompass various adversities, e.g., physical and\/or emotional abuse. Understanding the effects of different ACE types on various health outcomes can guide targeted prevention and intervention. We estimated the association between three categories of ACEs in isolation and when they co-occurred. Specifically, the relationship between child maltreatment, witnessing violence, and household dysfunction and the risk of being involved in violence, engaging in health-harming behaviors, and experiencing mental ill-health. Data were from eight cross-sectional surveys conducted in England and Wales between 2012 and 2022. The sample included 21,716 adults aged 18\u201369 years; 56.6% were female. Exposure to child maltreatment and household dysfunction in isolation were strong predictors of variant outcomes, whereas witnessing violence was not. However, additive models showed that witnessing violence amplified the measured risk beyond expected levels for being a victim or perpetrator of violence. The multiplicative effect of all three ACE categories demonstrated the highest level of risk (RRs from 1.7 to 7.4). Given the increased risk associated with co-occurring ACEs, it is crucial to target individuals exposed to any ACE category to prevent their exposure to additional harm. Implementing universal interventions that safeguard children from physical, emotional, and sexual violence is likely to mitigate a range of subsequent issues, including future involvement in violence.<\/jats:p>","DOI":"10.3390\/ijerph20176633","type":"journal-article","created":{"date-parts":[[2023,8,23]],"date-time":"2023-08-23T08:57:39Z","timestamp":1692781059000},"page":"6633","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["ACEtimation\u2014The Combined Effect of Adverse Childhood Experiences on Violence, Health-Harming Behaviors, and Mental Ill-Health: Findings across England and Wales"],"prefix":"10.3390","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0870-6847","authenticated-orcid":false,"given":"Rebekah Lydia Miriam","family":"Amos","sequence":"first","affiliation":[{"name":"School of Medical and Health Sciences, Bangor University, Wrexham LL13 7YP, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katie","family":"Cresswell","sequence":"additional","affiliation":[{"name":"School of Medical and Health Sciences, Bangor University, Wrexham LL13 7YP, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8097-3395","authenticated-orcid":false,"given":"Karen","family":"Hughes","sequence":"additional","affiliation":[{"name":"School of Medical and Health Sciences, Bangor University, Wrexham LL13 7YP, UK"},{"name":"World Health Organization Collaborating Centre on Investment for Health and Well-Being, Public Health Wales, Wrexham LL13 7YP, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark A.","family":"Bellis","sequence":"additional","affiliation":[{"name":"School of Medical and Health Sciences, Bangor University, Wrexham LL13 7YP, UK"},{"name":"World Health Organization Collaborating Centre on Investment for Health and Well-Being, Public Health Wales, Wrexham LL13 7YP, UK"},{"name":"Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,8,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.paed.2017.12.008","article-title":"Adverse childhood experiences","volume":"28","author":"Boullier","year":"2018","journal-title":"Paediatr. Child Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e356","DOI":"10.1016\/S2468-2667(17)30118-4","article-title":"The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis","volume":"2","author":"Hughes","year":"2017","journal-title":"Lancet Public Health"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Racine, N., Devereaux, C., Cooke, J.E., Eirich, R., Zhu, J., and Madigan, S. (2021). Adverse childhood experiences and maternal anxiety and depression: A meta-analysis. BMC Psychiatry, 21.","DOI":"10.1186\/s12888-020-03017-w"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1016\/j.bodyim.2022.01.003","article-title":"Adverse childhood experiences and body dysmorphic symptoms: A meta-analysis","volume":"40","author":"Longobardi","year":"2022","journal-title":"Body Image"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Afifi, T.O., Salmon, S., Stewart-Tufescu, A., and Taillieu, T. (2022). An Examination of Parents\u2019 Adverse Childhood Experiences (ACEs) History and Reported Spanking of Their Child: Informing Child Maltreatment Prevention Efforts. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph191710580"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1093\/pubmed\/fdu065","article-title":"Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: A national survey","volume":"37","author":"Bellis","year":"2015","journal-title":"J. Public Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1017\/S1474746419000101","article-title":"A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses","volume":"18","author":"Delpierre","year":"2019","journal-title":"Soc. Policy Soc."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1111\/jcpp.13135","article-title":"Practitioner Review: Twenty years of research with adverse childhood experience scores\u2014Advantages, disadvantages and applications to practice","volume":"61","author":"Lacey","year":"2020","journal-title":"J. Child Psychol. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1037\/amp0000768","article-title":"All adverse childhood experiences are not equal: The contribution of synergy to adverse childhood experience scores","volume":"76","author":"Briggs","year":"2021","journal-title":"Am. Psychol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"104331","DOI":"10.1016\/j.chiabu.2019.104331","article-title":"Questioning the use of adverse childhood experiences (ACEs) questionnaires","volume":"101","author":"McLennan","year":"2020","journal-title":"Child Abus. Negl."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1002\/jts.21833","article-title":"Synergistic Childhood Adversities and Complex Adult Psychopathology","volume":"26","author":"Putnam","year":"2013","journal-title":"J. Trauma. Stress"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"104492","DOI":"10.1016\/j.chiabu.2020.104492","article-title":"Synergistic adversities and behavioral problems in traumatized children and adolescents","volume":"106","author":"Putnam","year":"2020","journal-title":"Child Abus. Negl."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1016\/j.chiabu.2004.01.008","article-title":"The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction","volume":"28","author":"Dong","year":"2004","journal-title":"Child Abus. Negl."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"106455","DOI":"10.1016\/j.childyouth.2022.106455","article-title":"Childhood adversity subtypes and young adulthood mental health problems: Unpacking effects of maltreatment, family dysfunction, and peer victimization","volume":"137","author":"Sayyah","year":"2022","journal-title":"Child. Youth Serv. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1037\/fam0000510","article-title":"Adverse childhood experiences and prenatal mental health: Type of ACEs and age of maltreatment onset","volume":"33","author":"Atzl","year":"2019","journal-title":"J. Fam. Psychol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"112696","DOI":"10.1016\/j.socscimed.2019.112696","article-title":"ACEs are not equal: Examining the relative impact of household dysfunction versus childhood maltreatment on mental health in adolescence","volume":"245","author":"Negriff","year":"2020","journal-title":"Soc. Sci. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1002\/jts.22630","article-title":"Homicide as a Source of Posttraumatic Stress?: A Meta-Analysis of the Prevalence of Posttraumatic Stress Disorder after Committing Homicide","volume":"34","author":"Longobardi","year":"2021","journal-title":"J. Trauma Stress"},{"key":"ref_18","unstructured":"(2023, May 26). English Indices of Deprivation\u2014GOV.UK, Available online: https:\/\/www.gov.uk\/government\/collections\/english-indices-of-deprivation."},{"key":"ref_19","unstructured":"(2023, May 26). Welsh Index of Multiple Deprivation, Available online: https:\/\/statswales.gov.wales\/Catalogue\/Community-Safety-and-Social-Inclusion\/Welsh-Index-of-Multiple-Deprivation."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"707","DOI":"10.15585\/mmwr.mm7226a2","article-title":"Prevalence of Adverse Childhood Experiences among U.S. Adults\u2014Behavioral Risk Factor Surveillance System, 2011\u20132020","volume":"72","author":"Swedo","year":"2023","journal-title":"Morb. Mortal. Wkly. Rep."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"S144","DOI":"10.2105\/AJPH.2004.059204","article-title":"Causation and Causal Inference in Epidemiology","volume":"95","author":"Rothman","year":"2005","journal-title":"Am. J. Public Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1007\/s10654-005-7835-x","article-title":"Calculating measures of biological interaction","volume":"20","author":"Andersson","year":"2005","journal-title":"Eur. J. Epidemiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1111\/j.1467-8624.2009.01279.x","article-title":"Resilience Among Children Exposed to Domestic Violence: The Role of Risk and Protective Factors","volume":"80","author":"Bogat","year":"2009","journal-title":"Child Dev."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1177\/1077559507303778","article-title":"Cognition, Emotion, and Neurobiological Development: Mediating the Relation Between Maltreatment and Aggression","volume":"12","author":"Lee","year":"2007","journal-title":"Child Maltreat."},{"key":"ref_25","unstructured":"Bellis, M.A., Wood, S., Hughes, K., Quigg, Z., and Butler, B. (2023, August 21). Tackling Adverse Childhood Experiences (ACEs): State of the Art and Options for Action, Available online: https:\/\/www.ljmu.ac.uk\/-\/media\/phi-reports\/pdf\/2023-01-state-of-the-art-report-eng.pdf."},{"key":"ref_26","unstructured":"(2023, August 11). Violence Prevention Unit. Available online: https:\/\/www.violencepreventionwales.co.uk\/."},{"key":"ref_27","unstructured":"Newbury, A., Glendinning, F., Rodriguez, G.R., and Wilmot, R. (2023, August 09). Adverse Childhood Experience (ACE) and Trauma-Informed Approaches in Youth Justice Services in Wales: An Evaluation of the Implementation of the Enhanced Case Management (ECM) Proj An Evaluation of the Implementation of the Enhanced Case Management (ECM) Project. The Views and Experiences of Children and Youth Justice Workers. Available online: https:\/\/www.researchgate.net\/publication\/358911937."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1111\/jcpp.12621","article-title":"Lest we forget: Comparing retrospective and prospective assessments of adverse childhood experiences in the prediction of adult health","volume":"57","author":"Reuben","year":"2016","journal-title":"J. Child Psychol. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e12079","DOI":"10.1002\/jcv2.12079","article-title":"A systematic review and meta-analysis investigating the impact of childhood adversities on the mental health of LGBT+ youth","volume":"2","author":"Jonas","year":"2022","journal-title":"JCPP Adv."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/17\/6633\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:41:03Z","timestamp":1760128863000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/17\/6633"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8,23]]},"references-count":29,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2023,9]]}},"alternative-id":["ijerph20176633"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20176633","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8,23]]}}}