Adverse Childhood Experiences: Policy context
Derren Hayes
Tuesday, September 29, 2020
The basis for much of the work in the UK and internationally on adverse childhood experiences (ACEs) is drawn from a 1997 US study by CDC Kaiser on childhood traumas. This study identified a list of 10 ACEs that then formed the basis for a questionnaire used by researchers as a screening tool to assess the impact of childhood trauma on adults.
In the UK and elsewhere, the ACE questionnaire has been adapted to assess the impact of trauma on disadvantaged and vulnerable children. Answers to the questionnaire generate a score, the results of which are sometimes used to inform decisions about what interventions are provided.
Many of the ACE categories are forms of child abuse and neglect, which are known to harm children and are punishable by law, while others represent forms of family dysfunction that increase children’s exposure to trauma (see below).
THE 10 ADVERSE CHILDHOOD EXPERIENCES
- physical abuse
- sexual abuse
- psychological abuse
- physical neglect
- psychological neglect
- witnessing domestic abuse
- having a close family member who misused drugs or alcohol
- having a close family member with mental health problems
- having a close family member who served time in prison
- parental separation or divorce on account of relationship breakdown
However, there is no universally agreed definition of ACEs, and other countries and bodies have adopted slight variations to the list. For example, Public Health Wales in a 2017 survey investigating the childhood experiences of 2,500 Welsh adults included verbal abuse in its list of ACEs. The World Health Organisation has designed a far more extensive screening questionnaire than the original US version, and includes questions related to such adverse experiences as warfare.
Whatever list of ACEs is used, studies show they are widely prevalent. In its 2020 report on ACEs, the Early Intervention Foundation (EIF) points to the high proportion – around 80 per cent – of children in need of help and protection in England who are recorded as having at least one ACE (see graphics).
“This means that at least 2.5 per cent of all children living in England are experiencing some form of maltreatment or family dysfunction at any given point in time,” the EIF report states. “We also know that this statistic reflects only the tip of the iceberg, since the majority of child maltreatment cases go unreported.”
Retrospective surveys with adults, by contrast, suggest that at least 10 per cent will have experienced some form of abuse during their childhood. They also show that 40 per cent report experiencing at least one ACE in childhood and 10 per cent or more of the population will have experienced four or more ACEs before the age of 18 (see graphics).
Separate 2016 studies by Hughes and Ashton suggest slightly lower levels of adults reporting one ACE– one in five in Wales and nearly one in four in England – but slightly higher rates reporting four or more – 14 per cent in both countries.
However, the EIF report points out that the research is not able to reveal the extent of the risk nor the links between the different types of ACE and how these increase risk. Its 2020 report also highlights the challenges in collecting accurate information on child maltreatment. Adults can have difficulty in recalling abuse and neglect, which means retrospective studies could both over- and under-estimate the scale of the problem.
“Adults can have difficulty remembering their experiences of abuse, suggesting their memories are highly influenced by their current circumstances,” the report states.
The Hughes and Ashton studies found adults who reported experiencing four or more ACEs in childhood were at significantly greater risk of suffering health problems in adulthood, including mental ill health, substance abuse and life-limiting diseases.
Although most studies focus on a broad range of health-related outcomes, links have also been reported between ACE exposure and experience of wider social problems, such as reduced educational attainment, worklessness, diminished social mobility and lower socioeconomic status.
Professor Mark Bellis, of Bangor University and Public Health Wales, told the House of Commons science and technology committee’s 2018 inquiry into evidence-based early years interventions that experiencing ACEs also significantly increased the risk of an individual’s involvement with the criminal justice system.
In its evidence to the committee, the Academy of Medical Sciences echoed the concerns of the EIF about the problems with retrospective studies, pointing out that research was often targeted at specific groups, such as care leavers, resulting in cases being reported from only one perspective.
However, the committee concluded that “the volume and diversity of supporting evidence appears to make clear the correlation between suffering adversity in childhood and experiencing further negative outcomes in later life”. Its report cites Professor Sue White, of the University of Sheffield, who told it the correlations between childhood adversity and clinical problems were “totally unsurprising”.
To what extent experiencing childhood adversity causes problems in later life is subject to widespread debate (see research evidence). The British Psychological Society told the science and technology committee inquiry that childhood trauma can have an adverse impact on brain development leading to physical and behavioural changes. If this occurs over a long period, the child’s internal stress system can be damaged, which in turn can make them more vulnerable to experiencing physical and mental ill health throughout life, difficulties with emotional regulation and cognition problems.
However, a range of experts also told the committee that the medical profession’s knowledge of “pure causation” was limited. For example, it is unclear in the role played by the impact of socio-economic status in poor outcomes, the report states.
Using ACEs in practice
Armed with a growing body of evidence on the impact that adverse experiences in childhood can have on life outcomes into adulthood, some social care and health providers have recognised the potential that identifying children experiencing ACEs now could have for intervening early to mitigate negative effects in the long term.
These providers and commissioners started to build ACE questionnaires into their service design – known as ACE enquiry, the questionnaires are designed to generate better information about the family and social circumstances that children are living in and to understand the impact this is having on them.
This approach was initially targeted at most at-risk groups of children, such as those in contact with social services, in trouble with the law or experiencing mental health problems. However, in recent years, the use of ACE enquiry has grown to include children struggling at school, and standardised screening tools are now widely used by voluntary organisations, local authorities, the NHS and private sector providers.
“Universal ACE screening is also used by many frontline agencies to increase public awareness of childhood adversity and to help individuals access appropriate support,” the EIF report states. “In some cases, this screening is used to produce an ‘ACE score’, which reflects the number of ACEs experienced before the age of 18.”
In January, California became the first US state to implement an ACE screening programme for seven million children who qualify for state-subsidised medical care. Health care providers with two hours of online training will be encouraged to screen children up to the age of 18 for ACEs. Children’s caregivers and teenagers themselves will complete a questionnaire asking things like “Have you ever felt unsupported, unloved and/or unprotected?” The state hopes that the $160m initiative can cut the health impacts of early life adversity by as much as half within a generation.
There is no similarly comprehensive screening programmes being run in the UK – however, Scotland and Wales have developed their own ACE frameworks to shape policymaking in public health. In England, ACE screening is being widely used in child and adolescent mental health services, with scores being used to identify those in need of support.
However, combining responses about different experiences to generate an ACE score that can then be used as a gateway to interventions is problematic for many children’s services experts.
In evidence to the science and technology committee enquiry, Professor Rosalind Edwards of the University of Southampton warned that considering ACEs together was a “chaotic concept”, and that “conflating a lot of issues means that you cannot place much in the way of explanatory weight on them”. The NSPCC also told the inquiry that ACE terminology could “encourage a reductionist view of very complex experiences”.
“In policy and practice, any form of abuse encompasses a very wide spectrum of abusive incidents and experiences, involving a very wide range of relationships between victims and perpetrators, occurring in many different contexts, of different durations, and whose impact on each individual is mediated by a range of factors,” it told the inquiry.
This “misuse” of the ACE framework could see a high screening score becoming a “golden ticket” to support, and also cement a view of the child that their life outcomes are already written (see expert view). The EIF told the inquiry: “Limitations to this framework are not always fully understood by those trying to apply ACEs to their work with children. This had led to ACEs research being misapplied in practice, and we have encountered the ACE framework currently being used inappropriately. It should not be used to identify need and determine thresholds for prioritising who needs early intervention services.”
To guard against this, the NSPCC has called for comprehensive training on the strengths and weaknesses of the framework, so that practitioners understand that ACEs are not determinants of poor outcomes.
The growing recognition of ACEs and the desire to use the information gathered about the level of children’s exposure to adversity has seen local authorities and charities invest in trauma-informed approaches to support children and families affected. What constitutes trauma-informed practice is however open to debate due to the lack of any recognisable benchmarks to assess the quality of trauma-informed services in England.
In light of this knowledge vacuum, the devolved governments of Wales and Scotland, their public health departments and the NHS, have collaborated to develop best practice in evidence, research, standards for trauma training and service delivery. Sue Penna, chief creative officer at Rock Pool training consultancy, says the locally-driven approach in England is in stark contrast to the national drives in Wales and Scotland.
“There is a sense in these countries that as the agenda to address adversity in childhood and trauma informed approaches progresses, it does so safely; and safety is vital because if services are not safe, we will not be providing the right care for our traumatised communities,” adds Penna, who designed training on ACEs for frontline police officers for South Wales Police and South Wales Public Health.
For its ACE report, the EIF identified 33 interventions that it concluded have “robust evidence of preventing at least one of the 10 original ACE categories”, including reducing the health-harming behaviours associated with ACEs, and specifically reducing ACE-related trauma. These activities represent 10 separate intervention models that can be offered at the universal, targeted selective and targeted level, EIF says.
“If these evidence-based interventions were integrated into a comprehensive public health strategy developed in response to population needs, many ACEs could be prevented or substantially reduced,” it adds.
Different UK approaches
ACE policy and practice in England is currently being driven locally. For example, Bristol City Council has declared its aim to become an ACE-aware city, with around 20 per cent of public sector staff already being trained in trauma-informed practice. One of the three pillars of Birmingham Children’s Services Trust’s practice model is to use trauma-informed approaches to help children and young people overcome past trauma.
Meanwhile, Penna says police forces have “embraced” trauma-informed interventions to tackle ACEs most enthusiastically because they recognise this could help divert children from a pathway of youth offending to prison in adulthood. She cites the work of the Hampshire police and crime commissioner Michael Lane who awarded a £7,000 grant to charity CIS’ters, which supports victims of familial child abuse, to raise awareness of ACEs among professionals through the screening of an ACE documentary.
The 2018 Scottish programme of government included a commitment to prevent and mitigate ACEs, linking this to measures included in its Getting it Right for Every Child policy document – these include investing in health visiting services and the Family Nurse Partnership; tackling child poverty; and supporting perinatal and infant mental health. It sets out four areas of action: to support parents to prevent ACEs; support those who have experienced them; develop trauma-informed services; and to raise awareness across communities. This work has also been linked into achieving the National Performance Framework’s aim for children to “grow up loved, safe and respected, so that we realise our full potential”.
Scotland has developed a Knowledge and Skills Framework for Psychological Trauma, which sets out the essential and core knowledge and skills needed by all tiers of the Scottish workforce to ensure the needs of children and adults who are affected by trauma are recognised, understood and responded to in a way that recognises individual strengths, acknowledges rights, and ensures timely access to effective care, support and interventions for those who need it. This is being delivered through its National Trauma Training Programme. The Scottish government has also funded Public Health Scotland to pilot ACE enquiry in GP practices with adult patients.
Wales has taken a different approach. In 2017, the Welsh government part funded the creation of the ACE Support Hub, the aim of which is to help organisations and individuals to tackle ACEs by bringing experts together to share best practice and learning. It is run by Cymru Well Wales, a collaboration of voluntary sector organisations. In addition to sharing knowledge, the hub provides staff training and encourages new ways of working.
In its response to a report by care inspectorate Estyn, the Welsh government set out a series of measures it will pursue to improve its response to ACEs. These focus largely on how schools and local authorities can improve the sharing of information about vulnerable pupils and families, although the report also calls for schools to be mindful of the impact of ACEs on children and ensure they have access to “calm, nurturing and supportive spaces”. It also calls for authorities to assist schools to develop ACE-informed strategies to support vulnerable pupils.
Campaigners and experts y the more strategic approaches to tackling ACEs being taken by the devolved nations can, alongside local trailblazers, provide a blueprint for the Westminster government to develop a national strategy for England that also includes standards on evidence-based interventions.
ADCS VIEW
WE MUST DO MORE TO UNDERSTAND ACES, BUT RECOGNISE THEY HAVE THEIR LIMITS
By Jenny Coles, ADCS president 2020/21
The concept of adverse childhood experiences (ACEs) originated in America over two decades ago. The theory is that the more ACEs someone experiences, the greater their risk of poor outcomes in later life, in part because early exposure to toxic levels of stress arising from traumatic events can change the way the brain develops. This impacts on a child’s ability to navigate everyday life, which in turn increases their risk of developing health harming behaviours, including obesity and drug use.
Awareness of ACEs has grown in recent years and in many ways it offers us an accessible narrative for talking about the lifelong impact of trauma in early childhood. All to the good, but no two people, or their experiences, are ever the same and I worry about oversimplification. Childhood experiences and events can shape who we become as adults, but we also know that strong, consistent relationships can ease the worst effects of early adversity.
Ten traumatic events or circumstances, including domestic abuse and divorce, feature – however, other known determinants of poor health and wellbeing, such as social inequality or food insecurity, are not considered here. People’s lives, their vulnerabilities as well as their personal resilience and support networks cannot be easily captured via ACE screening tools; the love and support of siblings, stepparents or even a teacher can help a child to come to terms with grief or loss.
As you can tell, my feelings about ACEs are mixed. On the one hand, raising awareness of the impact of adversity on children’s lives and outcomes can open the door to new multi-agency responses. But on the other hand, the notion of working through a clinical checklist to arrive at a score can be limiting. This could retraumatise a child whose life and experiences do not fit within neat boxes, plus their risks or vulnerabilities can change over time. Instead, a holistic assessment of need is required as are strengths and relationship-based approaches to support to build resilience and empower children and young people.
An appreciation of ACEs can engender greater understanding of the challenges children face, and has real value in raising the awareness of childhood and family distress and adversity among the wider public, politicians and policy makers. However, this should not be used to label or stigmatise individuals or groups, such as children in our care.
It would be a significant step forward if the government took trauma-aware approaches to developing new policies, as would the prioritisation of early help and support to prevent the escalation of distress. An even bigger and bolder step would be the widespread adoption and use of trauma-informed responses across all public services. This public health-style response may help us to respond to the consequences of the pandemic. Covid-19 could be amplifying some challenges and may have given rise to many more. Plus, the economic fallout may be with us for years to come, so we do not yet know how this experience will impact on the lives and futures of children and young people.
EXPERT VIEW
CARE SECTOR NEEDS NATIONAL STANDARDS FOR TRAUMA-INFORMED APPROACHES
By Sue Penna, chief creative officer, Rock Pool
Working as an occupational therapist in acute and community mental health settings, I had felt like a lone wolf arguing that my clients’ distress should not just be seen through a diagnostic lens, that the early life experiences they described to me – child sexual abuse, neglect, violence, extreme poverty – has profoundly impacted on their ability to cope socially, emotionally and cognitively.
People struggle to manage when they have non-regulated stress responses, poor attachments and lack of trusting supportive relationships in their lives, and as a result can be targeted by those wishing to exploit them sexually and criminally.
I was lucky enough to visit centres of excellence in America and Canada informed by the ACE study that were using a trauma-informed approach with their community. This experience inspired me to develop recovery programmes for adults and children and young people who have experienced multiple ACEs.
The programmes have been written to educate and inform individuals about the impact of ACEs. They provide guidance on protective factors that help mitigate the impact of ACEs and practical methods to help develop resilience and cope with the adversity they have experienced and may do so in the future.
Since launching these programmes in September 2018, we have trained 600 frontline practitioners from across the UK to become ACE Recovery Toolkit facilitators.
It really felt like the time had come to address psychological trauma and its impact on individuals and communities.
But over the past 18 months, I have become concerned that ACEs and trauma-informed practice have become just more buzz words; the latest box to tick.
There has been discussion on social media and within the social care sector about using the original ACE checklist on children and as a screening tool for people to access services (or not). There is a lack of recognition of the added societal traumas, poverty and homelessness, inequality and now Covid-19 that contribute to childhood trauma and psychological distress.
Similarly, “trauma-informed approach” is a term banded around as though it’s something that can be done to people rather than something that requires a cultural shift in organisations.
Suddenly, there are experts everywhere and while this may be the case, in England we have no benchmarks to assess the quality of trauma-informed service delivery.
Contrast this to the devolved governments of Wales and Scotland. Their public health departments and NHS have collaborated to develop best practice evidence, research, standards for trauma training and service delivery. There is a sense in these countries that as the agenda to address adversity in childhood and trauma-informed approaches progresses, it does so safely; and safety (a key element in a trauma-informed approach) is vital because if services are not safe, we will not be providing the right care for our traumatised communities. This is even more vital as we continue to live in a world dominated by a pandemic.
There is no such national strategy in England, no standards for practitioners/trainers or clients to benchmark against. No vision and now no Public Health England to even lead on this. Where work is being done nationally, it is hard to access and is not inclusive.
These are challenging and exciting times, but we need to get it right or the agenda will shift again and the opportunity to transform people’s lives will be lost and “another new best thing” will arrive.
As practitioners and caring professionals, we need to hold the hope for our communities, to help resilience flourish and enable recovery.
- Sue Penna is co-founder of Rock Pool, a training and consultancy service for the care sector, and author of The Recovery Toolkit
FURTHER READING
ACE: What we know, what we don’t know, and what should happen next, Early Intervention Foundation, February 2020
Knowing your children: supporting pupils with adverse childhood experiences, Welsh government response to Estyn report, January 2020
Evidence-based early years interventions, Science and technology committee, HM Parliament, November 2018
Routine enquiry about adverse childhood experiences: pilot evaluation final report, Department for Health and Social Care, May 2018
National trauma training framework for Scotland, NHS Education for Scotland, 2018
Knowledge and Skills Framework for Psychological Trauma, NHS Education for Scotland, 2017