Identifying adverse childhood experiences with electronic health records of linked mothers and children in England: a multistage development and validation study

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Adverse childhood experiences (ACEs) are potentially traumatic or neglectful events that can significantly impact children’s health and development. Identifying and measuring ACEs is crucial for early intervention and reducing long-term health risks. However, the lack of validated indicators in routine electronic health records (EHRs) poses a significant challenge for policy makers and service providers.


The study used a population-based birth cohort in England, linking EHRs of mothers and children. Candidate ACE indicators were identified through a systematic review. A multistage prediction framework was used to develop clinically relevant indicators of child maltreatment and maternal intimate partner violence (IPV). An expert panel provided relevance ratings, and indicators were grouped into ACE domains.


A total of 63 ACE indicators were identified, representing six distinct domains: maternal mental health problems, maternal substance misuse, adverse family environments, child maltreatment, maternal IPV, and high-risk presentations of child maltreatment. Validation estimates demonstrated good predictive performance for identifying any child maltreatment or maternal IPV.


The ACE domains align with clinically meaningful presentations of vulnerable families seeking healthcare. The prevalence of ACEs recorded in primary and secondary care during the 2 years before and after birth was 39.1% for any ACE, highlighting the importance of early primary care responses and think-family approaches.


The study’s findings underscore the potential of linked EHRs to identify ACEs in vulnerable families and prompt early support for mothers and children. ACE indicators could aid in resource prioritization and the development of trauma-informed care plans. However, routine implementation requires careful pilot testing to address ethical considerations and potential harms.


This study represents a significant step in developing clinically relevant ACE indicators in EHRs. It offers valuable insights for policymakers, service providers, and researchers working towards early intervention to support children and families exposed to ACEs. Further research and pilot testing are needed before implementing ACE indicators in routine healthcare settings.

Dr Shabeer Syed, Clinical Psychologist & Senior Research Associate

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