The aim of the project was to introduce into maternity services a screening tool for women and their partners at booking, in order to identify adverse childhood exper iences (ACEs) and improve professional response to risk, build parental resilience and strengthen parenting capacity.
Background
Analysis of serious case reviews (SCR) has shown that the largest proportion of non-accidental incidents involving significant harm, maltreatment or death, occur in the youngest children (Sidebotham et al, 2016; Brandon et al, 2020). In the most recent triennial review of a total of 368 SCRs from 2014–2017, 42% (154) involved children aged under one year (Brandon et al, 2020). Serious and sometimes fatal maltreatment may take place within the family, with children living at home, or with relatives at the time of the injury (Brandon et al, 2020).
Local audit of presentations to the Trust through the county emergency department, or direct referral from GPs in 2017/2018, identified six non-mobile infants who had suffered serious injury while in the care of parents, including one death caused by non-accidental injury. A non-mobile infant was defined as an infant of age six months or less (an infant who is unable to move independently from lying to sitting with stability and therefore unlikely to have caused injury to themselves by their activities). Infants of this age are inherently vulnerable and dependent on parents or carers to meet all their needs. The county birth rate for 2017/2018 was 6 317 live births. For the purposes of this audit, serious injury was defined as an infant presenting with one or more of the following: fractures, traumatic brain injury, intra-abdominal trauma, intra-thoracic trauma, burns greater than 5% total body surface area, injuries or events requiring PICU admission or death.
In 2018/2019, 10 non-mobile infants experienced serious injury while in the care of their parents, one progressed to SCR. The birth rate for 2018/2019 was 6 088 live births. The increase in incidence from the previous year was concerning and a driver for maternity service improvement to better assess and reduce risk.
National SCRs (Sidebotham et al, 2016) have highlighted the importance of considering factors which impact on parenting capacity within assessments, sharing information more effectively and improving engagement with fathers. Local SCRs have identified that the risks associated with significant adults in a child's life are not always known and vulnerabilities in parents are not always identified (Nicolas, 2019; Czyz, 2020). Parenting assessments were often, therefore, incomplete, risks not fully understood and families consequently did not always obtain the support they needed.
ACEs are specified traumatic events occurring before the age of 18 years, originally described by Felitti et al in 1998. The association between ACEs and poor developmental, health and social outcomes in childhood, adolescence and adulthood has been well-documented (Pechtel and Pizzagalli, 2011; Bellis et al, 2014; Kerker et al, 2015; Bright et al, 2016; Hughes et al, 2017; Oh et al, 2018; Hughes et al, 2020; Kan et al, 2020). Women who have a history of ACEs are more likely to experience obstetric risks such as smoking, preterm delivery, antenatal and postnatal depression (Leeners et al, 2014; Christiaens et al, 2015; Angerud et al, 2018; Olson, 2018). Men who have a history of ACEs are more likely to exhibit signs of anxiety and depression during their partner's pregnancy (Skjothaug et al, 2015). More research is required with respect to the relationship between ACEs in men and their parenting (Romanowicz, 2019). Evidence suggests that some ACEs are perpetuated through generations, unless the cycle of adversity can be broken by effective interventions to improve outcomes for the child. (Olson, 2018; Panisch et al, 2020).
There is increasing recognition that the care provided in the antenatal period can minimise potential future harm through early assessment of risk, intervention and support (Leadsom et al, 2013). Pregnancy has been identified as an opportune moment for health-related behaviour changes in women (Olander et al, 2016; Olson, 2018). Discussing the potential impact of ACEs upon the health of their child could trigger changes in behaviour of the parents which the midwife would be well-placed to facilitate. These changes could improve outcomes for children. Identifying ACEs can allow for targeted support from professionals, such as midwives, or third-sector organisations. Such support has been shown to be effective in increasing parental confidence, skills and knowledge in women who have experienced domestic abuse, have a history of substance misuse, or experience homelessness. All these situations present potential ACEs for the baby (Balaam and Thomson, 2018). Research also suggests that promoting the potential of fathers with support and education in parenting and relationship skills would help break the ongoing cycle of ACEs (Minnesota Fathers and Families Network, 2014).
‘Better births’ sets out the five-year view of NHS maternity services (NHSE, 2016). Helping a family to provide the best start in life is an integral part of this vision to improve safety and provide personalised care, resulting in better long-term health for women and their families. Improving outcomes for those using maternity services through a focus on prevention has the potential to create significant savings to the health economy (NHSE, 2016). Mental illness alone places significant financial pressure, not just on the health service, but also educational, criminal and social systems. The financial advantage of early identification of ACEs and provision of early help would be of benefit to all sectors (Hughes et al, 2020). The local maternity system and transformation programme recognised the potential of utilising ACE enquiries within maternity services and supported the project as part of their prevention work stream.
The county ACEs strategy was launched at a conference in 2018. The evidence presented supported the association between early adversity and many health risks, and emphasised the opportunities for preventative work to build resilience and improve outcomes (Action on ACEs Gloucetershire, 2018). A team was established and linked the project to the local Trust Safety and Quality Improvement Academy Silver Award programme to provide support and structure with implementation and evaluation.
Literature review
A literature review was undertaken at the outset to establish the use of ACEs within maternity services both within and outside the UK. This was done using the Embase, Cinahl and Psychinfor databases using search terms including ‘adverse childhood experience*’ and maternity or antenatal or prenatal or neonatal and ‘midwi* or health visit*’. Further literature was obtained through a general internet search, reference lists of identified articles or publisher websites.
The national household survey of adults in England demonstrated that almost half the population, 46.4% had experienced at least one ACE (Bellis et al, 2014). Despite the prevalence of ACEs, the authors were able to identify only limited published evidence relating to antenatal screening for ACEs (Smith et al, 2016; Johnson et al, 2017; Flanagan et al, 2018; Mersky et al, 2019, Nguyen et al, 2019). None of these studies were carried out within the UK.
In one retrospective Canadian study (Racine et al, 2018), women were asked to recall any ACEs using a questionnaire adapted from the original ACEs checklist (Felitti et al, 1998). Those women who experienced physical/emotional abuse in childhood were found to be significantly more likely to enter pregnancy with a chronic health condition and to have psychosocial difficulties in their pregnancy. Women who were exposed to household dysfunction in childhood were also significantly more likely to experience psychosocial difficulties during pregnancy. The overall variance accounted for by ACEs was small (in the region of 3%–19%) but significant.
A Department of Health project explored the development and implementation of routine enquiry about childhood adversity across a child and adolescent mental health service (CAMHS), drug and alcohol service, and sexual violence support service (Quigg et al, 2018). The project team developed and piloted an implementation pack which enabled services to use a routine enquiry questionnaire with clients focussing on ACEs and child sexual exploitation in children aged 14 years and above. Where routine enquiry was implemented, it was generally reported as acceptable to practitioners and clients. The conclusion was that routine enquiry during assessment should only be implemented if it provided direct benefit to the client, minimised risk of harm, and promoted recovery and support processes.
A study into ACEs enquiry during routine postnatal contact by health visitors across Anglesey invited mothers to complete an ACE questionnaire (Bellis et al, 2014). A total of 321 mothers took part, 91% agreed that the ACE enquiry from health visitors was acceptable; 43% said it was the first time they had told professionals about their experiences; 66% agreed or strongly agreed that the help/support received was improved because the health visitor understood their childhood better. These findings provided reassurance that asking about ACEs would be acceptable in maternity services and could potentially enhance the support and help received by families.
Despite the increasing body of evidence in support of routine ACE enquiry (Bright et al, 2016; Johnson et al, 2017; Oh et al, 2018), caution must be exercised. Finkelhor (2018) argued that it may be unwise to implement widespread ACEs-based screening until we have a better understanding of effective interventions.
Trauma-informed interventions to strengthen protective factors are recommended when working with parents with ACEs (Panisch et al, 2020). Developing resilience through access to a trusted adult in childhood, supportive friends, positive social connections or being engaged in community activities has been shown to boost resilience and improve outcomes, even in those who experience high levels of ACEs (Brown and Shillington, 2017; Panisch et al, 2020). A meta-analysis by Schofield (2013) suggests that a trusted relationship in adulthood is also important in reducing risk to the child. The midwife is well-placed to provide or signpost such support. ACEs are an important public health issue and prevention of childhood adversity is more desirable than later intervention (Finkelhor, 2018).
Current practice
Prior to implementing the service improvement, standard practice in the maternity service was for midwives to complete a vulnerability assessment screening proforma when a woman booked with her midwife. The vulnerability assessment enquired about risk factors, such as those associated with social circumstances, mental health, substance misuse, involvement with social care and any current or previous domestic abuse. In those women and families where a risk factor was identified, a safeguarding/vulnerability communication form was then submitted to the vulnerable women's team. This prompted a range of referrals to other services and the initiation of safeguarding pathways where appropriate.
The vulnerability assessment identified useful information, however, there was no discussion directly with the partner or routine enquiry into either partners' experiences in childhood. Importantly, in light of a number of previous SCRs within the county (Nicolas, 2019; Czyz, 2020), information on the father was limited. Identifying any risks associated with the partner, or offering any support on their journey to becoming a parent, was consequently extremely challenging. A key aim of the project was to seek a greater understanding of both parents, to establish the parental exposure to ACEs and explore current circumstances in order to minimise the infant's exposure to ACEs and mitigate risk. The intention was to facilitate an exploration of existing protective factors and sources of support with parents and develop a personalised plan to provide enhanced support.
Project design
The project piloted a service improvement with a defined cohort of women and their partners. At booking for maternity services, existing practice already involved midwives screening women for vulnerabilities using the vulnerability assessment screening proforma and women were asked to consent to information sharing with other agencies. Therefore, no further consent was sought in relation to this project.
Multistage evaluation of the project took place through a mixed-methods approach with quantitative and qualitative data collection, integration and analysis. A pragmatic mixed-methods approach was selected in order to combine the strengths of both paradigms. This is increasingly commonly used within nursing research to achieve meaningful results around the effectiveness and acceptability of interventions (Bressan et al, 2016; Fabreques and Pare, 2018). Quantitative data was collected in the form of copies of completed anonymised ACEs screening tools. Analysis of the data included exploring rates of ACEs disclosure, gender differences in the disclosure rates, the impact of the presence of a partner upon disclosure and frequency of occurrence of each ACE. Qualitative evaluation of the project was obtained from both professionals and service users through anonymous questionnaires. Thematic analysis was used to identify, analyse and report themes which arose from the data collected, to improve the ability to communicate the data effectively (Nowell et al, 2017).
Method
Initially a process map of a woman's journey through maternity services was drawn up. Opportunities to implement routine enquiry into ACEs were identified as shown in the process map in Figure 1.
Figure 1. Process map of adverse childhood experiences (ACEs) enquiries during pregnancy
Tools developed as part of the Gloucestershire ACEs strategy were reviewed and amended to produce a bespoke toolkit which was more appropriate for service users and professionals in maternity, while retaining the integrity of the original design. Tools were developed to introduce the concept of ACEs to service users (through use of the M card, Figure 2) in order to screen for ACEs in parental histories (Figure 3), identify potential ACEs for the newborn, ascertain what existing protective factors were present and establish sources of support to build resilience and reduce risk (Figure 4).
Figure 2. M card; a small folded leaflet the size of a credit card given to women with the booking pack to explain the meaning of adverse childhood experiences (ACEs) and the five ways to wellbeing, a self-help aid to reduce the impact of ACEs. As well as being an aid to parents, this tool was used by midwives to help start the conversation about ACEs 
Figure 3. Screening tool used to identify adverse childhood experiences (ACEs) in childhood but also experiences in adulthood 
Figure 4. Ecomap to identify people and activities that currently help and could help to build resilience
A distinction between this study and others is that in this project, exploration was made into parental exposure to ACEs and adult exposure (over the age of 18) to adverse experiences both in the past and present. Training on ACEs, the new process, use of the tools, and dealing with disclosure was developed and delivered to the midwives recruited to the project ahead of its launch.
For two months, the screening tool replaced existing documentation when booking all women in a specified geographical area. The area was selected as it covers a wide range of socio-demographic groups and would test sensitivity, specificity and acceptability of tools with as varied a cohort as possible. A baseline audit of maternity cases from the same area over the same time frame a year previously was undertaken to establish social or safeguarding themes and rates for comparison.
Midwives introduced the ACEs screening tool to booking women and their partners (if present). Following completion, a discussion took place to enable the ecomap to be populated and any support needs identified, leading to development of a mutually agreed, individualised plan for the family. This may have included signposting or referral to other agencies, either voluntary or statutory. If necessary, existing safeguarding pathways were utilised. Communication channels with health visitors and GPs were updated to facilitate sharing ACEs-based information relating to both women and their partners.
The number of ACEs identified was not added together as is usual for assessment of risk of long-term harm in order to reach a perceived significant threshold. This was a considered decision as the project team felt that even one ACE could have a significant impact on the welfare and safety of an infant and should be addressed (Brown et al, 2019). The ACE or ACEs identified were used to initiate discussion with a focus on development of support plans. These were reviewed at specified intervals and amended or updated as required. Opportunities were given for either partner to reopen the ACEs conversation with their midwife at any time if they so wished. In particular, where women booked with their partners present, the midwife ensured that she was asked again about domestic abuse at an appointment when she was seen alone.
Following the booking appointment and ACEs conversation, women and their partners were asked to complete an anonymous feedback questionnaire and return this in a postage-paid envelope to the project team. Midway through the pilot, all eight midwives participating in the project were contacted to identify any concerns or ongoing support needs they might have and seek formative feedback. Summative feedback from them was canvassed by questionnaire at the end of the pilot period. Qualitative feedback was analysed to identify themes.
Information governance
In consultation with the Trust information governance advisor, it was decided that for the duration of the pilot project, completed screening tools would be held securely by the project team while ecomaps and support plans would be kept in the handheld maternity notes by the woman. This allowed for real-time quantitative analysis of the incidence and range of ACEs identified.
Ethics
The project team was conscious of the sensitive nature of enquiries when using the screening tools to support a conversation about both ACE's and vulnerabilities in adulthood. The potential for these enquiries to cause distress was considered. Midwives are already well-trained and experienced in having difficult conversations but the need for additional training and support was recognised and addressed. Where significant numbers or particularly concerning disclosures of ACEs were made, the project team contacted the booking midwife to discuss support plans for the family and offer advice in real time. Expert guidance was sought around data governance and extensive conversations were had over confidentiality and how and where to record ACEs. Issues identified included where paternal ACEs should be recorded and what detail on parental ACEs could appropriately be recorded in the neonatal records. As detailed previously, it was decided that for the duration of the pilot project, completed parental screening tools would be securely held by the project team, ensuring that all neonatal medical records held evidence of the ACE enquiry having taken place and a summary of any plans or interventions.
A priority was to ensure that within neonatal services, or at future presentations as an infant or child to the Trust professionals would be aware of any risks, protective factors and support plans and be in a position to update or build upon them. It was agreed with the Trust information governance team, that a summary of the ACEs enquiry, containing the same information as shared with the health visitor and GP, would also be transferred routinely into the neonatal medical record at delivery, whether ACEs were identified or not.
Results
Quantitative data was obtained from 44 pregnant women and 23 partners. Of the 44 women, 25 disclosed one or more ACE during their childhood (57%), demonstrating that the screening tool was effective in identifying ACEs. The most frequently reported ACEs are shown in Figure 5a and Figure 5b. The same proportion of partners disclosed ACEs, although the mean number of ACEs was much reduced to 0.78 as opposed to 1.5 in pregnant women.
Figure 5a. Most frequently reported adverse childhood experiences (ACEs) in mother 
Figure 5b. Most frequently reported adverse childhood experiences (ACEs) in partner
Mothers with a partner present at booking reported fewer childhood ACEs and adversities in adulthood see Figure 6. Partners reported low levels of ACEs and adversities in adulthood.
Figure 6. Comments from parents
Qualitative analysis of feedback from professionals indicated that most midwives felt comfortable asking the ACEs questions at booking. However, if a midwife had experienced ACEs themselves, it was difficult for them to have a conversation with the parents. One midwife said:
‘ACEs have been experienced by many of those now expected to offer support while silently coming to terms with this new knowledge about ourselves and on our own children's future.’
The ACEs project had an impact not only on those midwives directly involved in the project but also those throughout the maternity services as they gradually became more ACE-aware through their mandatory training. Self reports from midwives indicated that, for some, this new knowledge had a positive impact on both their personal life and professional practice.
Midwives' comments reflected a desire for more training and increased knowledge of support services available and the need for some refinement of the ACEs toolkit. Encouragingly, health visitors offered input to support amendments to the toolkit to ensure it met their needs.
A total of nine parents provided qualitative feedback: 90% thought that booking was the right time to be asked about ACEs or adversities in adulthood, although the discussion was not always easy; 24% found the conversation to be very uncomfortable. Examples of the range of comments are provided in Figure 7. These comments indicated that women and partners required more information and warning about the ACEs conversation in advance of the booking. On further investigation, it became apparent that some women and partners had only received the M card during the conversation at the booking.
One woman was unable to disclose that she was in a violent relationship as her partner was in the same room when completing the questionnaire. However, the domestic abuse was disclosed during a further conversation with the midwife when she was seen alone. Families reported that where support was identified, they would like a follow-up from the midwife to ensure agreed plans were implemented in a timely manner.
Parents gave positive feedback and appeared to be reassured that they could have an open conversation with a health professional, especially if they had experienced ACEs during their own childhood.
Discussion
The maternity ACEs project was a pilot for a service improvement and, consequently, the numbers involved were small. A unique element of the project was the inclusion of partners in the ACEs screening conversation. Approximately half the women had their partners present at booking. Due to the restricted time frame, there was no further opportunity to collect ACEs screening data from the parents. We cannot make assumptions about the reason for lack of attendance of partners as there are a number of possible explanations, single parents, relationship breakdown, work commitments, personal decision not to attend. These were not explored during this study.
The project focussed primarily on the feasibility of introducing ACE-based enquiry and support into routine maternity care and obtaining qualitative feedback from professionals and parents rather than obtaining statistical data on the prevalence of ACEs. This limits the ability to compare findings to larger scale research projects, however, some basic comparisons have been made to establish the effectiveness of the tools.
The rates of disclosure for one or more ACE were 57%, higher than that described in the general population by Bellis et al (2014) or identified in mothers by Hardcastle and Bellis (2019). While the numbers in the pilot were small, they do suggest that the tools used were sensitive enough and were used by professionals in a way that enabled parents to disclose issues which had affected them. The partners (all men) disclosed fewer numbers of ACEs, and the women described more complex family situations which increased their average number of ACEs to almost twice that of the men. The reasons for this are unknown but likely to be multifactorial. It is possible that the recall or perception of childhood amongst the men differs from that of the women (Minnesota Fathers and Families Network, 2014). Alternatively, the reality of their childhood may have been different as for example girls may be more likely to be victims of certain ACEs than boys (Marryat and Frank, 2019). Overall, however, research on gender differences and the impact on ACEs disclosure is inconclusive. All the midwives in this project were female which may have influenced disclosure rates. Further research through a large scale study would be required to explore these factors further.
A distinctive feature of this project was that in addition to ACEs, the screening tool was used to capture adversity experienced during adulthood, both past and present, in order to assess the risk of ACEs for the unborn baby. The rates of adversity in adulthood were low amongst both men and women at around 26% with a mean 0.55; 37% of babies were due to be born into a family where they would experience one or more ACEs due to parental adversity in adulthood. These findings contrast with literature which suggests that up to 50% of children have exposure to ACEs (Bethell et al, 2017). It is possible that adult adversity has been under-reported, or that some partners not involved during the pregnancy may increase ACEs for the child following birth.
The impact of partners' presence on disclosures of adult adversity was a concern to the project team and midwives. While disclosure rates differed amongst women with partners present and those without, this was not mentioned as a concern in any of the feedback from women. In one instance, a woman later disclosed domestic abuse to her midwife which she had not shared at the initial ACEs enquiry due to the partner's presence. Women may choose not to disclose abuse on initial questioning as they may fear for their own safety. However, asking sends a message that concerns can be raised at a later date (Salmon et al, 2015). This reinforces the importance of always providing additional opportunities to ask about domestic abuse at a separate appointment when the woman is alone.
The acceptability of the ACE-based enquiry was an integral part of the project and it was reassuring to note that support from parents for routine enquiry was high, reflecting the findings from the literature (Bethell et al, 2017; Johnson et al, 2017; Olson, 2018; Hardcastle and Bellis, 2019; Rariden et al, 2020). In addition, studies in pregnant women indicate that having a conversation about ACEs increases trust with their professional and helps the professional understand them better (Flanagan et al, 2018).
Table 1. Maternal reported adverse childhood experiences (ACEs) and adversities in adulthood in presence or absence of partner
| ACEs in childhood | Adversities in adulthood | |
|---|---|---|
| Partner present at booking | 43% | 13% |
| Partner not present at booking | 71% | 43% |
A significant number of booking mothers and partners reported finding the ACEs discussion uncomfortable. It was unclear what influenced the level of discomfort experienced by the parents in this study. A higher number of ACEs, with the exception of parental divorce, has previously been associated with greater discomfort (Mersky et al, 2019). Mersky et al (2019) found that more than 80% of clients were not at all or only slightly uncomfortable with an ACEs questionnaire, and only 3% reported extreme discomfort when questions were asked in a home setting. Flanagan et al (2018) used an ACEs screening tool in pregnancy which was administered by telephone. Most participants were comfortable completing the questionnaires (91%) and discussing ACEs with their clinician (93%), and agreed that professionals should ask antenatal women about ACEs (85%). In this project, no direction was given as to where the questions were asked other than face-to-face, therefore questions may have been asked in either the family home or in clinic setting, and this might have influenced the level of discomfort experienced.
Previous studies have also demonstrated an association between clinician and patient discomfort during screening (Mersky et al, 2019). Further education is necessary to support midwives in making the conversation more comfortable for themselves and for parents.
Training in trauma-informed and strengths-based approaches has been planned as the literature suggests that this would be beneficial to ensure professionals have the skills to respond to disclosure (McCormick, 2019; Rariden et al, 2020). Raising awareness of ACEs in society should normalise conversations with professionals so that enquiry becomes routine practice. Action on ACEs Gloucestershire (2018) recognises that all professionals, voluntary organisations and communities must have a good understanding of ACEs, in order to respond to the impact ACEs can have on people and communities.
A theme identified in the feedback from midwives reflected their desire for further training to enable them to better support parents after disclosures. Parents reported finding the support provided as useful, this echoes the findings amongst health visitors from the work by Hardcastle and Bellis (2019) and of Quigg et al (2018). Bespoke training delivered by the county action on ACEs team was provided to the midwives in the project before launch; however, they reported needing greater understanding of what would prevent ACEs and to feel more confident in social prescribing to support families to build resilience and reduce risk. The project team recognise and support the need to strengthen training. Work with the local early help teams and health and wellbeing hub has already started and further training is planned in line with the relaunch and expansion of the project later in 2020. It would be wrong to continue to conduct routine ACEs enquiry without being able to offer comprehensive and effective support following disclosures (Finkelhor, 2018; Quigg et al, 2018).
Feedback from professionals regarding the tools was mostly positive. Suggestions were made for some refinement, in particular, concerning the ecomap and these points have been addressed prior to relaunch of the project. One finding that had not been predicted was the difficulty some midwives reported if they themselves had experienced ACEs. However, it was reported that for some practitioners it provided them with the impetus to make changes in their own personal lives. Future training will reinforce the protective impact of stable, supportive relationships to mitigate the effects of ACEs (Schofield et al, 2013) and encourage midwives to access psychological support and clinical supervision.
Conclusion
This project attempted to identify ACEs in families who use maternity services in order to improve the professional response to risk, build parental resilience and strengthen parenting capacity. A bespoke toolkit was developed and successfully piloted. The toolkit was found to be effective in identifying ACEs for parents and their unborn baby.
Opportunities to strengthen and develop the support offer made to families were identified. Work is in progress to build relationships with local early help teams and the county's health and wellbeing hubs to increase midwives' confidence in coordinating offers of support to build parental resilience and strengthen parenting capacity. Plans are in place to expand and relaunch the project later in 2020 to further support women and their partners to provide a nurturing environment and build resilience to protect future generations from a cycle of adversity.
Key points
- The association between adverse childhood experiences (ACEs) and poor health and social outcomes are well-documented but have not been explored well within maternity services in the UK
- A bespoke toolkit was developed and found to be effective and acceptable in identifying ACEs at booking within a maternity setting
- Early identification of ACEs creates opportunities to strengthen and develop the support offer made to families by maternity services
- Midwives are well-placed to support women and families to identify risk, build parental resilience and strengthen parenting capacity. This could help protect future generations from a cycle of adversity
CPD reflective questions
- What factors influence disclosure of adverse childhood experiences (ACEs) and adversity in adulthood?
- How can you help foster a relationship where parents feel comfortable to discuss ACEs or adversity in adulthood?
- How can you engage with partner agencies to better support families, build resilience and promote positive parenting?
- How might you talk about and take action on ACEs in your own practice setting?