The term “adverse family environments” refers to any clinically intervenable psychosocial risk factor or experience recorded in the child or the parent that met the pre-defined inclusion criteria. The AFE domain broadly aligns with the original ACE domain titled “household challenges” from the CDC-Kaiser ACE Study, supplemented with clinically relevant definitions to select indicators consistent with the UK guidance for identifying families in need, and the US Preventive Services Task Force for social risk domains. The AFE domain includes indicators from multiple social risk domains covering clinical concerns relating to housing instability (e.g., homelessness), “criminal behaviours in the household”, food insecurity, education and financial strains, transportation difficulties, utility needs, aspects of interpersonal safety that are not already addressed by other ACE domains. This domain also incorporates Royal College of General Practitioners recommended indicators for recordings that should raise a cause for concern (e.g. coded observations include various concerns in parent or child such as: “life crisis”, “concerned about appearance”, “history of other physical trauma”, “anger or aggressive behaviours”, etc.).

Indicator list

Code list

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Adverse family environment (977)



Syed S, Gilbert R, Feder G, Howe LD, Powell C, Howarth E, Deighton J, Lacey RE. Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England. The Lancet Public Health. 2023 Jul 1;8(7):e520-34.

Syed S, Gonzalez-Izquierdo A, Allister J, Feder G, Li L, Gilbert R. Identifying adverse childhood experiences with electronic health records of linked mothers and children in England: a multistage development and validation study. The Lancet Digital Health. 2022 Jul 1;4(7):e482-96.

Syed S, Ashwick R, Schlosser M, Gonzalez-Izquierdo A, Li L, Gilbert R. Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis. Archives of disease in childhood. 2021 Jan 1;106(1):44-53.

Gonzalez‐Izquierdo A, Ward A, Smith P, Walford C, Begent J, Ioannou Y, Gilbert R. Notifications for child safeguarding from an acute hospital in response to presentations to healthcare by parents. Child: care, health and development. 2015 Mar;41(2):186-93.

Relevant references

Woodman J, Gilbert R, Allister J, Glaser D, Brandon M. Responses to concerns about child maltreatment: a qualitative study of GPs in England. BMJ open. 2013 Dec 1;3(12):e003894.

Woodman J, Allister J, Rafi I, de Lusignan S, Belsey J, Petersen I, Gilbert R. A simple approach to improve recording of concerns about childmaltreatment in primary care records: developing a quality improvement intervention. British journal of general practice. 2012 Jul 1;62(600):e478-86.

Eder M, Henninger M, Durbin S, Iacocca MO, Martin A, Gottlieb LM, Lin JS. Screening and interventions for social risk factors: technical brief to support the US Preventive Services Task Force. JAMA. 2021 Oct 12;326(14):1416-28.

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Dr Shabeer Syed, Clinical Psychologist & Senior Research Associate