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Adverse childhood experiences in firstborns associated with poor mental health of siblings

    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.

    To download the paper: Adverse childhood experiences in firstborns and mental health risk and health-care use in siblings: a population-based birth cohort study of half a million children in England – The Lancet Public Health

    Or for further information, please contact Shabeer at s.syed.16@ucl.ac.uk

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    Reaching a consensus: Technology-facilitated abuse conceptualisation, definition, terminology, and measurement

      The rapid development of digital systems has benefited modern societies but also created opportunities for the proliferation of harms. Specifically, the term ‘technology-facilitated abuse’ (TFA) describes the misuse or repurposing of digital systems to harass, coerce, or abuse. It is a global problem involving both existing and emerging technologies.

      TFA is regularly discussed in the context of domestic abuse, where it is perpetrated via a range of systems, including phones, laptops, and tablets, smart home/Internet of things appliances, as well as online accounts, that are either shared or accessed without the partner’s consent. In the United Kingdom, 32% of women and children who sought support for domestic abuse in 2022 to 2023.

      The research field lacks comprehensive and standardised measurement tools and in 2022, the UN Secretary-General emphasized that the absence of agreed definitions and measures impedes any efforts to understand the true scale of TFA. Despite significant work across research, policy, and practice to understand the issue, the field operates within linguistic, conceptual, and disciplinary silos, inhibiting collaboration.

      To address this, the present study led by Dr Nikolaos Koukopoulos (University College of London) in collaboration with VISION researchers Dr Madeleine Janickyj and Dr Leonie Tanczer used the Delphi technique to reach a consensus on TFA conceptualization, definition, terminology, and measurement among subject experts.

      Following a literature review, a global, cross-disciplinary sample of academics, practitioners, and policymakers (n = 316) reflected on TFA across three survey rounds. The results showed both aligned and opposing perspectives. “Technology” and “facilitated” were the most preferable terms. Still, there was uncertainty regarding the need for additional terminologies to denote the scope of abuse, such as gendered descriptors. Participants had little familiarity with existing TFA measurement tools, with two-thirds unaware of any.

      Most experts agreed on conceptualising TFA based on the perpetrator’s behaviour, the victim’s harm and impact, and consent. They also supported an expansive TFA definition, beyond intimate relationships, that can involve groups and communities as perpetrators or targets. However, they were more reluctant to perceive TFA as a distinct abuse form, or one guided by social norms, legal thresholds, or involving child perpetrators.

      Recommendations:

      • The fragmentation and contrasting conceptualisations of TFA observed in this research underscore the need for greater cross-disciplinary communication among researchers, practitioners, and policymakers to move closer toward a unified understanding of TFA. Some form of standardization is particularly crucial, given the rapidly developing ways existing and emerging technologies are weaponized in the digital realm. Concrete, practical steps could help bridge these divides by consolidating published work into a searchable database. This could include suggestions for conceptually similar terminology across various sectors and subject areas.
      • Furthermore, an interactive online map of key TFA stakeholders and research groups could facilitate greater collaboration and knowledge-sharing, which the research team is now working on.

      To download the paper: Defining and Conceptualizing Technology-Facilitated Abuse (“Tech Abuse”): Findings of a Global Delphi Study – Nikolaos Koukopoulos, Madeleine Janickyj, Leonie Maria Tanczer, 2025

      To cite the paper: Koukopoulos, N., Janickyj, M., & Tanczer, L. M. (2025). Defining and Conceptualizing Technology-Facilitated Abuse (“Tech Abuse”): Findings of a Global Delphi Study. Journal of Interpersonal Violence, 0(0). https://doi.org/10.1177/08862605241310465

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      Systems analysis of service coordination in domestic abuse, primary care and child mental health services

        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 download the paper: Domestic abuse, primary care and child mental health services: A systems analysis of service coordination from professionals’ perspectives – ScienceDirect

        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

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        Better utilisation of healthcare data to measure violence

          Despite violence being recognised as a harm to health, it is not consistently or adequately captured in healthcare data systems. Administrative health records could be a valuable source for researching violence and understanding the needs of victims, but such datasets are currently underutilised for this purpose.

          VISION researcher Dr Anastasia Fadeeva, with input from Dr Estela Capelas Barbosa, Professor Sally McManus and Public Health Wales’ Dr Alex Walker, examined violence indicators in emergency care, primary care, and linked healthcare datasets in the paper Using Primary Care and Emergency Department datasets for Researching Violence Victimisation in the UK.

          Anastasia worked with Hospital Episode Statistics Accident and Emergency (HES A&E) and the Emergency Care Data Set (ECDS) while on secondment at the Department of Health and Social Care (DHSC), with helpful review provided by researchers in the department.

          Among the datasets reviewed in the study, the South Wales Violence Surveillance dataset (police and emergency department data linked by Public Health Wales) had the most detail about violent acts and their contexts, while the Clinical Practice Research Datalink (CPRD) provided the more extensive range of socioeconomic factors about patients and extensive linkage with other datasets. Currently, detailed safeguarding information is routinely removed from the ECDS extracts provided to researchers, limiting its utility for violence research. In the HES A&E, only physical violence was consistently recorded.

          Addressing these limitations and increasing awareness of the potential utility of health administrative datasets to violence-related research has the potential to provide insight into the health service needs of victims.

          For further information please see: Social Sciences | Free Full-Text | Using Primary Care and Emergency Department Datasets for Researching Violence Victimisation in the UK: A Methodological Review of Four Sources (mdpi.com)

          Or contact Dr Anastasia Fadeeva at anastasa.fadeeva@city.ac.uk

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          A health perspective to the war in Israel and Palestine

            Gene Feder, VISION Director and Professor of Primary Care at the University of Bristol, has written an opinion piece with colleagues commenting on events in Israel and Gaza from a public health and primary care perspective. Responding to the war in Israel and Palestine was published in December in the online edition of the British Journal of General Practice.

            Gene and his colleagues are GPs working to further the development of family medicine in the occupied Palestinian territory, specifically in the West Bank, but with links to family medicine in Gaza through the United Nations Relief and Works Agency and through Medical Aid for Palestinians. They also have friends and family in Israel and Palestine.

            They have three responses to the current crisis as informed by their work as GPs and connection to Palestinian primary care:

            1. A plea for the protection of health care and health professionals amid the war
            2. A plea for the preservation of public health amid war
            3. A recognition that in the aftermath of October 7th and the invasion of Gaza, the widespread direct and vicarious trauma in Israeli and Palestinian populations will result in permanent physical and emotional damage: the former in the shape of orthopaedic, neurological, and gynaecological (as a result of rape) harm, the latter in the form of widespread anxiety, depression, and post-traumatic stress disorder which will also cascade down the generations.

            Given VISION’s commitment to developing evidence on violence prevention, we will be organising roundtable meetings bringing together researchers focusing on post-conflict violence reduction. This is an opportunity for dialogue, perhaps leading to new perspectives and research including systematic assessment of sustainable post-conflict interventions as well as further joint activities.

            For further information on the opinion piece, please see: Responding to the war in Israel and Palestine

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            Cost effectiveness of primary care training & support programme for secondary prevention of DVA

              Recent research evaluated the cost-effectiveness of the Identification and Referral to Improve Safety plus (IRIS+) intervention compared with usual care using feasibility data derived from seven UK general practice sites.

              IRIS+ is a training and support programme for clinicians working in primary care to aid in their identification of those experiencing or perpetrating domestic violence / abuse (DVA).

              VISION Deputy Director, Dr Estela Capelas Barbosa and Director, Professor Gene Feder, worked with their University of Bristol colleagues to conduct a cost–utility analysis, a form of economic evaluation comparing cost with patient-centred outcome measures, as a means to measure the benefit obtained from the treatment or intervention.

              The specific cost-utility analysis they conducted assessed the potential cost-effectiveness of IRIS+ which assists primary care staff in identifying, documenting and referring not only women, but also men and children who may have experienced DVA as victims, perpetrators or both.

              The analysis showed that in practices that adopted the IRIS+ intervention, a savings of £92 per patient occurred. The incremental net monetary benefit was positive (£145) and the IRIS+ intervention was cost-effective in 55% of simulations (when the model is repeated with different assumptions).

              The research team therefore concluded that the IRIS+ intervention could be cost-effective in the UK from a societal perspective though there are large uncertainties. To resolve these the team will conduct a large trial with further economic analysis.

              For further information please see: Primary care system-level training and support programme for the secondary prevention of domestic violence and abuse: a cost-effectiveness feasibility model | BMJ Open

              Or contact Dr Estela Capelas Barbosa at e.capelasbarbosa@bristol.ac.uk

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              COVID-19 adaptations to a training and support programme to improve primary care response to domestic abuse

                Dr Estela Capelas Barbosa, VISION Deputy Director has recently published, COVID-19 adaptations to a training and support programme to improve primary care response to domestic abuse: a mixed methods rapid study in the BMC Primary Care journal, with Lucy Downes, IRIS Network Director.

                Increased incidence and/or reporting of domestic abuse (DA) occurred during the COVID-19 pandemic. As a result of the lockdowns across the UK, services providing support to victims had to adapt and consider adding methods of remote outreach to their programmes.

                Identification and Referral to Improve Safety (IRIS) is a programme to improve the response to domestic abuse in general practice, providing training for general practice teams and support for patients affected by DA. The COVID-19 pandemic required those running the programme to adapt to online training and remote support.

                Estela and Lucy employed a mixed methods rapid approach to this research in order to gather evidence around the relevance, desirability and acceptability of IRIS operating remotely. Quantitative IRIS referral data were triangulated with data from surveys and interviews. They found that the adaptation to online training and support of IRIS was acceptable and desirable.

                This study contributes to practice by asserting the desirability and acceptability of training clinicians to be able to identify, ask about DA and refer to the IRIS programme during telephone/online consultations. The findings from this study may be of interest to (public) health commissioners when making commissioning decisions to improve the general practice response to domestic abuse.

                For further information please see: COVID-19 adaptations to a training and support programme to improve primary care response to domestic abuse: a mixed methods rapid study | BMC Primary Care (springer.com)

                Or contact Dr Estela Capelas Barbosa at e.capelasbarbosa@bristol.ac.uk

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