Research suggests that adverse childhood experiences can have a lasting influence on children’s development that result in poorer health outcomes in adulthood. Like other exposure-outcome relationships, however, there is uncertainty about the extent to which the relationship between adverse childhood experiences and health is causal or attributable to other factors.
The aim of this systematic review is to better understand the nature and extent of the evidence available to infer a causal relationship between adverse childhood experiences and health outcomes in adulthood.
A comprehensive search for articles will be conducted in four databases (Medline, CINAHL, PsycInfo and Web of Science) and Google Scholar. The team, led by Dr Lisa Jones of Liverpool John Moores University, and includes VISION researchers Professor Mark Bellis and Professor Sally McManus, will review studies published since 2014:
of adults aged 16 years or over with exposure to adverse childhood experiences before age 16 years from general population samples;
that report measures across multiple categories of childhood adversity, including both direct and indirect types; and
report outcomes related to disease morbidity and mortality.
To cite: Jones L, Bellis MA, Butler N, et al. Interpreting evidence on the association between multiple adverse childhood experiences and mental and physical health outcomes in adulthood: protocol for a systematic review assessing causality. BMJ Open 2025;15:e091865. doi: 10.1136/bmjopen-2024-091865
Domestic violence and abuse (DVA) is prevalent within the United Kingdom (UK) and has severe and long-lasting physical and mental health consequences. An estimated 2.3 million adults in England and Wales (4.8%) experienced domestic abuse in the past 12 months. More women than men experience DVA, and women experience more repeated abuse, more physical, sexual, and emotional violence and coercive control, more injuries, and greater fear.
We, in the VISION research consortium, investigate how DVA is related to health. This policy briefing summarises evidence from five of our recent publications. We highlight the key recommendation resulting from across the research and discuss the key findings and evidence demonstrating the prevalence of DVA and the need for a cross-government approach to violence prevention.
Key Recommendation
A cross-government approach to preventing violence needs to include health services, alongside justice, welfare, education and other sectors. An effective and safe NHS response to survivors of domestic violence needs to be implemented. That response, embedded in training for healthcare professionals and referral to appropriate services, stretches from identification of survivors to initial support, to addressing the mental health and other sequelae of violence. Currently, the response is sporadic and patchy, with many Integrated Care Boards (ICBs) not commissioning necessary services. Integrated commissioning, as recommended in the NICE guidelines, could help bridge silos and sectors.
Key findings
Domestic violence and abuse (DVA) affects the physical and mental health of victim-survivors.
About half of people who attempted suicide in the past year had experienced violence from a partner at some point in their life, and one in four experienced violence from a partner in the preceding year
The type of intimate partner relationship and the type of violence and abuse affects the nature and level of physical and mental health consequences.
People who use violence against their partners also tend to have worse mental health, and mental health services present an opportunity for intervention with this group.
To cite: Blom, N., Davies, E., Hashemi, L., Obolenskaya, P., Bhavsar, V., & McManus, S. (2025). VISION Policy Briefing: Domestic violence and abuse and mental and physical health. City St George’s, University of London. https://doi.org/10.25383/city.28653212.v3
Adverse childhood experiences (ACEs) often affect multiple children within families, yet studies tend to focus on the health outcomes of individual children, underestimating the needs of affected families. First author Dr Shabeer Syed (UCL Great Ormond Street Institute of Child Health), VISION Director and Professor Gene Feder, and colleagues aimed to examine the association between firstborns exposed to ACEs between 1 year before and 2 years after birth (the first 1000 days) and the risks of mental health problems, mental health-related health-care contacts, and all-cause hospital admissions in multiple children from the same mother, compared to firstborns without ACEs.
The first-of-its-kind study, published in The Lancet Public Health and funded by the National Institute for Health and Care Research Policy Research Programme, found that mothers whose firstborns had experienced adverse childhood experiences had a 71% increased risk of having children (aged five -18) with mental health problems, compared to mothers whose firstborn did not experience adversity.
This translates to 12 additional children with mental health problems for every 100 mothers whose firstborn experienced adversity.
These findings underscore the pervasive risk that early adversity can have on multiple children in the family, and the importance of early identification and sustained support for vulnerable families beyond the first 1,000 days of a child’s life.
As part of the study, researchers analysed linked GP and hospital health records from 333,048 first-time mothers and their 534,904 children (firstborns and siblings) born in England between 2002 and 2018. They focused on six different forms of adverse childhood experiences in the firstborn child recorded during their first 1,000 days of life (from conception up until the age of two).
These included: child maltreatment, intimate partner violence, maternal substance misuse, maternal mental health problems, adverse family environments (e.g. homelessness), and high-risk presentations of child maltreatment (e.g. unexplained child injuries).
Over a third (37.1%) of firstborn children had at least one recorded adverse childhood experience. The most common adverse childhood experiences were living with maternal mental health problems (21.6%), followed by adverse family environments (14.5%) such as parental criminality and housing instability.
Approximately one in five (19.8%) mothers had at least one child with a recorded mental health problem between the ages of 5 and 18.
The risk of mental health problems was consistent across all siblings, regardless of birth order (firstborn vs thirdborn), in families where the firstborn experienced adverse childhood experiences.
Lead author Dr Syed said: “Whilst previous research has focused on the impact of adverse childhood experiences on individual children, our study reveals a cascading health risk that extends beyond the individual, impacting on the health of siblings as well.
“This likely stems from the continuation of adverse childhood experiences within the family. When a child or parent presents with mental health concerns, violence or other forms of adversity, it’s essential to ask about the wider family context.”
As a result of their findings, the team are also calling for further research into the impact of early health visiting and primary care support.
Co-author, Professor Feder, said: “General practice teams have a key role in identifying first-born children experiencing adverse childhood experiences and in supporting first-time parents to help reduce the impact of adverse childhood experiences on the whole family, including subsequent children.
“We need further evidence for effective interventions to reduce that impact, particularly on mental health.”
Study limitations
The researchers could not investigate adverse childhood experiences related to fathers’ mental health or substance use as healthcare data from fathers could not be linked to their children.
The study found that adverse childhood experiences in firstborns were associated with mental health outcomes in the first and subsequent children, but this does not necessarily mean that adverse childhood experiences cause mental health problems.
Additionally, electronic health-care records underestimate intimate partner violence and child maltreatment due to non-disclosure and/or detection and under-recording by clinicians.
The impact of intimate partner violence (IPV) on parental and child mental health is well documented, as is the associated increased use of healthcare services by survivors of IPV. UK policy emphasises the importance of partnership working between health services and domestic abuse agencies, along with clear referral pathways for victims of violence and abuse and co-ordinated local responses. However, in general, current policy and guidance is focused on the response to adult victims with more limited advice as to how this should be operationalised for working with children.
With first author Dr Claire Powell (University College of London), VISION researchers Dr Olumide Adisa and Professor Gene Feder and others explored how services work together to support parents and children experiencing both parental IPV and parental or child mental health problems by drawing on the perspectives of professionals working in primary care, children and young people’s mental health services (CYPMHS), and domestic abuse services.
The team conducted a qualitative study, interviewing professionals in geographically contrasting local authority areas in England. They carried out framework analysis using a systems approach and mapping techniques to understand the service interrelationships and boundary judgements of professionals.
Results showed that
The relationships between domestic abuse services, CYPMHS, and primary care were complex, involving funders and commissioners, local authority strategic groups, and wider services such as schools and children’s centres.
Participants consistently identified a gap in the relationship between statutory CYPMHS and domestic abuse services.
There were mental health service gaps were for children living with ongoing or intermittent IPV and for children and parents with needs falling below or between service thresholds.
There was a gap in services for users of abusive behaviour to prevent future IPV.
Staff perspectives revealed differing views on treating the effects of trauma, and the co-ordination and sequencing of care.
Improving the response to children and adults experiencing mental health problems in the wake of IPV requires a systems perspective to understand the barriers to service co-ordination. The findings indicate a particular need to address the gap between CYPMHS and domestic abuse services.
To cite the paper: Claire Powell, Olumide Adisa, Lauren Herlitz, Shivi Bains, Sigrún Eyrúnardóttir Clark, Jessica Deighton, Shabeer Syed, Ruth Gilbert, Gene Feder, Emma Howarth, Domestic abuse, primary care and child mental health services: A systems analysis of service coordination from professionals’ perspectives, Children and Youth Services Review, Volume 169, 2025, 108076, ISSN 0190-7409, https://doi.org/10.1016/j.childyouth.2024.108076
Violence can be categorised in a variety of ways for example physical, sexual, emotional, and domestic but all cause significant physical and mental morbidity within general populations. Individuals with a severe mental illness have been found to be significantly more likely to experience domestic, physical, and sexual violence compared to the general population. For these individuals, experiences of violence are important risk factors however, this is not routinely collected by mental health services.
In general data on all forms of violence has been inadequately available from healthcare records. This is partly due to the lack of routine enquiry by professionals at points of clinical contact, and partly because instances of violence are difficult to identify in healthcare data in the absence of specific coding systems.
A general challenge for using health records data for research is that the most valuable and granular information is frequently contained in text fields (e.g., routine case notes, clinical correspondence) rather than in pre-structured fields; this includes mentions of violence whether experienced as a victim or perpetrated. Capturing violence experiences across mental healthcare settings can be challenging because most instances are likely to be recorded as unstructured text data. Therefore, natural language processing (NLP), is increasingly in use to extract information automatically from unstructured text in electronic health records, particularly in mental healthcare, on clinical entities.
Dr Ava Mason from Kings College London and VISION researchers Professor Robert Stewart, Dr Angus Roberts, Dr Lifang Li, and Dr Vishal Bhavsar worked with colleagues to apply NLP across different clinical samples to investigate mentions of violence. They ascertained recorded violence victimisation from the records of 60,021 patients receiving care from a large south London NHS mental healthcare provider during 2019. Descriptive and regression analyses were conducted to investigate variation by age, sex, ethnic group, and diagnostic category.
Results showed that patients with a mood disorder, personality disorder, schizophrenia spectrum disorder or PTSD had a significantly increased likelihood of victimisation compared to those with other mental health diagnoses. Additionally, patients from minority ethnic groups for Black and Asian had significantly higher likelihood of recorded violence victimisation compared to White groups. Males were significantly less likely to have reported recorded violence victimisation than females.
The researchers demonstrated the successful deployment of machine learning based NLP algorithms to ascertain important entities for outcome prediction in mental healthcare. The observed distributions highlight which sex, ethnicity and diagnostic groups had more records of violence victimisation. Further development of these algorithms could usefully capture broader experiences, such as differentiating more efficiently between witnessed, perpetrated and experienced violence and broader violence experiences like emotional abuse.
To cite: Mason AJC, Bhavsar V, Botelle R, Chandran D, Li L, Mascio A, Sanyal J, Kadra-Scalzo G, Roberts A, Williams M, Stewart R. Applying neural network algorithms to ascertain reported experiences of violence in routine mental healthcare records and distributions of reports by diagnosis. Frontiers in Psychiatry 2024 Sep 10. doi:103389/fpsyt.2024.1181739
A report just published by the Department for Work and Pensions (DWP) further confirms high levels of trauma and mental distress among people not in employment and approaching benefits services for support. The report focuses on those in receipt of Employment and Support Allowance (ESA) aimed at people with an impairment or health condition that affects how much work they do.
VISION researcher Sally McManus, with colleagues Claire Lapham and Ann Conolly from the National Centre for Social Research, analysed the government’s main mental health study. They found that nearly one in three (30%) ESA recipients screened positive for post-traumatic stress disorder. This was more than twice the rate for Jobseeker’s Allowance (JSA) claimants (12%), and ten times that of employed people (3%). The analyses show that the claimant population experienced high levels of stress, in which self-confidence was low and anxiety high. Compared to those in employment, few ESA claimants owned their home and many faced serious debt arrears.
Sally presented findings from this study as oral evidence to the Work and Pensions Committee’s Inquiry into Safeguarding Vulnerable Claimants, including domestic violence victims. She drew attention to calls from Women’s Aid for reform they highlight is needed to make the benefits system the lifeline survivors need, rather than a source of re-traumatisation and further harm.
Women’s Aid recommendations include implementing a named domestic abuse lead in every Jobcentre Plus and ensuring staff receive regular, specialist domestic abuse training, so that work coaches and other frontline staff are better able to recognise claimants experiencing domestic abuse. Specialist domestic abuse services need to be properly funded to support and advocate for survivors in making their claims to DWP. Extending the domestic violence easement to up to a year would also help, alongside exempting those who are moving to or from refuges from repayment of Jobcentre Plus advances.
An aim of the VISION programme is to examine the nature and extent of contact that people with experience of violence have with various health and justice services.
However, much less is known about the effects of violence on the close relatives of victims. This is particularly surprising considering the critical role that relatives play in providing support, care, and advocating for victims in the aftermath of violence.
Cook, E. and McManus, S. (2024). Indirect victims of violence: mental health and the close relatives of serious assault victims in England. Social Science & Medicine.
Adolescent domestic abuse (ADA) goes by many names, sometimes referred to as toxic teenage relationships. ADA includes physical, emotional, and/ or sexual abuse that occurs between young people who are, or were, dating. It is often overlooked in research, policy and practice. As a phenomenon, abusive behaviour between adolescents in intimate relationships remains relatively invisible, due in part to the persistent yet unfounded assumption that domestic abuse is something that only occurs between adults.
The Crime Survey for England and Wales finds that women aged 16 to 19 are more likely to experience domestic abuse than older age groups (ONS, 2020), but despite the prevalence, women in this age group are less likely to be referred to support services (SafeLives, 2017).
SafeLives discovered, on average, experiencing abusive behaviour from a partner begins at age 14 or 15, (2017). Further research in Wales found that among those aged 11-16 years old experienced a range of mental health and social impacts associated with experiencing domestic abuse, including teenage pregnancy, self-harm, and violent behaviour (Young et al, 2021).
With this landscape in mind and led by the need from our partners and to ensure intersectoral collaboration, VISION set up a working group with Thames Valley Police, SafeLives, Islington Borough Council, H.O.P.E Training, Respect, Youth Realities and others to investigate ADA via three activities:
ADA rapid systematicreview to synthesise existing research and data on ADA in teenage relationships (January 2024; funded by the City St George’s, UoL, Policy Support Fund).
ADA workshop: ‘Too Soon, Too Late’ organised by VISION with SafeLives Changemakers and young people who experienced abuse in their relationships when they were aged 13 to 16 (March 2024; funded by the City St George’s, UoL, Participatory Research Fund).
ADA conference, an event to bring together practitioners, people with lived experience, police, researchers, and policymakers working in the ADA environment (April 2024; funded by the City St George’s, UoL, HEIF KE Fund).
The report, Summary of the VISION Adolescent Domestic Abuse activities and events in 2024, is available online. It summarises the findings and recommendations of the review, workshop and conference for a roundtable of police, local government, academics, practitioners and specialist services working in the field held in June 2024. It was produced for the working group as an aid to distil the thinking thus far across the three VISION activities.
ADA Rapid Systematic Review
The VISION review investigates ADA by examining the terminology and related terminology used in the literature. The paper focuses on the perpetration and victimisation as it concerns adolescents, especially those under 16 years old, and the factors that act as protective and recovery mechanisms for young people experiencing ADA.
VISION researchers, led by Dr Ruth Weir, conducted a systematic rapid review of 79 papers from databases for peer-reviewed literature.
The team discovered definitional issues, an overemphasis on quantitative studies, and a lack of attention to ADA when it intersects with cultural factors, gender differences, criminalisation, and poor mental health. Many of the studies report on school-based settings, with limited reporting and understanding of the role of neighbourhood factors in acting as protective and recovery mechanisms. Additionally, literature on impacted adolescents and their help-seeking behaviours is sparse. The review revealed that evidence on abuse affecting adolescents in the UK remains patchy.
Highlights from the VISION ADA rapid review: Gaps, limitations & considerations for future research
ADA workshop:Too Soon, Too Late
Dr Polina Obolenskaya and Dr Annie Bunce, VISION Research Fellows, collaborated on a consultation project, “Too soon, too late”, with the SafeLives Changemakers and with young people who experienced abuse in their relationships when they were aged 13 to 16. The main aim of the consultation was to develop a robust, methodological framework for a future adolescent domestic abuse (ADA) research proposal.
Together with SafeLives, a charity working to end domestic violence, they co-developed the material for the online workshop, a focus group, with young people, which took place in March 2024, and was facilitated by the ‘Changemakers’, a group of young people passionate about amplifying the voices of survivors of domestic abuse. They work alongside SafeLives providing a young person’s expertise on the charity’s work, conducting research, and working to influence policy change.
Some of the preliminary themes from the workshop include:
Lack of recognition amongst young people of both domestic abuse (DA) in general, and ADA specifically.
Young people don’t easily identify their own experiences of ADA as DA.
Young people’s understanding of ADA changes over time.
Young people highlighted the wide variation in experiences of ADA and professional responses to it.
Young people can identify clear priorities for future ADA research.
Young people see school as a key point of early intervention, but feel that improvement is needed in terms of better education around healthy relationships and school cultures that encourage open discussion around DA whilst actively challenging attitudes and behaviours conducive to ADA and sexual violence.
Further information can be found in the report available for downloading online.
ADA Conference
The Adolescent Domestic Abuse conference held on 18 April brought together 161 academics, practitioners, and policy makers to share existing research, policy and practice. Dr Ruth Weir, Senior Research Fellow at the Violence & Society Centre and the VISION research project at City, and Katy Barrow Grint, Assistant Chief Constable at Thames Valley Police, welcomed the delegates.
Louise Rolfe, OBE, Metropolitan Police and National Police Chief Council lead for Domestic Abuse was a keynote speaker. Louise spoke about the national context of domestic abuse, highlighting the most harmful abuse that is seen is coercive control and that domestic abuse accounts for more than 30% of violent crime. She also spoke about the role of the media requiring scrutiny and the need for sustainable long-term systemic solutions.
Professor Christine Barter, Co-Director of the Connect Centre for International Research on Interpersonal Violence and Harm, University of Central Lancashire, also gave a keynote. She provided an overview of her 15 years of research exploring the prevalence, subjective impact and risk factors associated with abuse in young people’s relationships in her presentation, Researching abuse within teenage relationships: A critique of a decade’s work and what we could do better. Her mixed-method body of work addressed both victimisation and perpetration for young people aged 13 to 17.
There were panels on Teenage relationships and abuse: What the research says; Sexual violence in teenage relationships; and Specialist services and local government. Presenters included academics sharing their ADA research from Loughborough University and Durham University and specialist domestic violence organisations like SafeLives, Refuge, and Women’s Aid. Islington Borough Council, representing local government, discussed their work on a multi-agency model project to identify, intervene and protect teenagers experience ADA.
Workplace bullying and harassment (WBH) is bad for people’s health, and this negative health impact can manifest in a variety of ways and be long-lasting.
Over a decade ago the UK government initiated the Fair Treatment at Work survey, aiming to ‘place the issue of bullying at work on employers’ agendas’, yet there has been no major initiative since.
Using data from the 2014 Adult Psychiatric Morbidity Survey, VISION researchers Annie Bunce, Ladan Hashemi and Sally McManus, along with Carrie Myers and Charlotte Clark from City St George’s, University of London and Stephen Stansfeld from Queen Mary, University of London, examined the prevalence and nature of WBH among workers in England, and associations with mental health.
A clear picture of the severity of the problem of WBH in England is painted by four key findings.
One in ten people in paid work reported having experienced WBH in the past year. This is likely to be an underestimate due to underreporting for various reasons;
Those who reported bullying were more likely to be in a financially disadvantaged position;
Over half of people who reported having been bullied at work identified the perpetrator as a line manager; and
Clinically diagnosed common mental disorder was more than twice as likely in employees with experience of WBH compared with those without, and those exposed to WBH were also twice as likely as others in paid work to screen positive for PTSD.
Taken together these findings demonstrate that WBH is common in UK workplaces, it may be driven and exacerbated by issues of inequality, power and hierarchical organisational structures, and it is associated with depressive and anxiety disorders severe enough to warrant health service intervention and treatment.
This power dynamic should not be forgotten when addressing issues in the workplace, but the complexity of workplace environments creates challenges for identifying, understanding and addressing bullying. Reports of WBH can coincide with performance concerns from managers, and, whilst behaviours intended as legitimate performance management activities might be misinterpreted as bullying by the employee, it is also possible that HR practitioners attribute managerial bullying behaviours to legitimate performance management practice to exonerate mangers and protect the organisation.
This links to a recently published piece for The Conversation by Sally McManus and Kat Ford (Bangor University), which sets out how companies can influence and perpetuate violence in society, including via employment practices that conceal the extent of bullying, sexual harassment and other forms of workplace violence (for further information see Six ways companies fuel violence (theconversation.com).
Also, structural issues in the workplace can create pressure for managers which they then take out on those they manage, managers can be victims of WBH themselves, and organisational culture may perpetuate WBH.
Given such complex power dynamics, it is recommended that organisations involve employees at all levels in the development of policies, and collaboratively review the implementation and performance of policies regularly to ensure they are working for the people they are intended to protect. Rather than prescribed ‘tick box’ policies and responses, creative methods incorporating employees’ perspectives may more likely lead to meaningful change.
