We have all been exposed night after night to the extreme adversity of children and young people exposed to war. We are all concerned how these children will survive, will cope and how they can grow up without the dark shadow of adversity stalking and affecting their lives. It is timely that the Association of Child and Adolescent Mental Health has established a Special Interest Group concerned with Adverse Childhood Experiences – ACEs. The mission of the group is to help integrate and to develop research, and critical understanding of the complex nature of adversity in childhood, formulated as Adverse Childhood Experiences and the implications for practitioners across services for children and young people.
We are inviting colleagues across the spectrum of Mental Health, Health, Social Care, and Education to join ACAMH’s Adverse Childhood Experience Special Interest Group, to become active members to contribute, question and share their understanding, and knowledge in this complex, growing and vital field of knowledge. We have developed an online forum to discuss the topic and to network. You do not have to be an ACAMH Member to join the SIG or use the forum. You can join via the ACAMH website.
Information on the Forum
You will find a great deal of information about research in the field of ACEs on the forum. Information is gathered into sections, with references. The sections including;
How ACEs are defined and the Cycle of ACEs
Since Kempe’s description of the Battered Child Syndrome in 1962, different forms of child maltreatment have been recognised – physical, emotional, sexual abuse, neglect and exposure to violence in the home. The co-occurrence of different forms of maltreatment has been recognised – poly-victimisation. Vincent Fellitti and his colleagues (1998) introduced the notion of Adverse Childhood Experiences creating a cumulative risk index of ten items which could be summed into an ACEs score – a measure which has been utilised extensively in research studies. Significant stressors in the child’s life, including parental alcohol substance abuse, and mental health problems, divorce, separation, family violence and incarceration were added to the basic forms of maltreatment. The finding that high levels of adversity were associated with a life-time of mental and health difficulties, was widely recognised as a significant finding, replicated across many subsequent research enquiries. A cycle of aces is recognised, childhood adversity is associated with harmful adolescent and adult outcomes, in turn parenting is affected, and the care of children triggering further adversities perpetuating the cycle.
The future of research on Adverse Childhood Experiences
A recording of a recent panel discussion is included on the forum which considers ‘The future of research on Adverse Childhood Experiences’. The panel discussion provides up to the moment thinking on the future of research and priorities, which will be valuable for the special interest group in terms of future development
What we do, and don’t know about Adverse Childhood Experiences
The areas explored in the Forum of What we do, and don’t know about Adverse Childhood Experiences’ includes a review on ‘How ACES should be measured. Although used widely there is growing awareness of the limitations of the ACEs score, which has been used across a wide range of research, demonstrating the population link between adversity and long-term physical and mental health outcomes. However, there is growing awareness of the need to take into account a much wider range of adverse influences in the community, associated with health and equity, deprivation racism and disadvantages.
We need to understand a great deal more about the ‘Pathway from childhood adversity to adult physical and mental health difficulties’. In the Forum, we have reviewed the growing field of longitudinal research, following children through adolescence to adult life. We now have information about possible pathways, and an awareness that we need to balance cumulative risk and adversity, balancing, risk, resilience and vulnerability factors from the individual, from parenting, the family and community to make for a more nuanced understanding of potential pathways.
Another important area where we need to develop knowledge is to understand the ‘Prevalence of ACEs in the community’. There is an extensive literature on the prevalence of the core forms of maltreatment, physical, sexual and emotional abuse and exposure to violence. With the addition of a wide range of household dysfunctions such as parental mental health, substance abuse, separation, loss, divorces and community violence associated with different forms of adverse experiences, there is a a significant challenge to assess the prevalence of ACEs
‘Intervention to modify and prevent the impact of ACEs’ presents a considerable challenge. The introduction of Trauma-informed approaches has the potential to transform the views and responses of the workforce in relation to the needs and responses of children and young people and adults referred to mental health, safeguarding, offending and care services, and children and young people looked after or living in contexts of significant stress of adversity. However, the evidence for the effectiveness of these approaches, both short term and longer-term reduction of harmful psychological and physical health is limited, and at an early stage.
ACEs and application to clinical work, public policy and public health – modifying the impact of ACES
One of the results of the introduction of ACEs was the observation that a common factor in the direct effects of adversity on children and young people was exposure to trauma and associated traumatic responses. ‘Toxic Stress’ was the term applied to exposure to prolonged stressful experiences. The neurobiological impact of traumatic and stressful events has been described as resulting in a “cascade of toxic stressful, inflammatory and hormonal responses with marked effects on brain morphology, function and network architecture”
Based on the evidence of potential harmful impact of ACEs, Hughes et al (2017) argue that ‘ACE Trauma informed practice can (should) be developed across multiple settings’:
- including schools,
- criminal justice agencies,
- social care assessments of children and their families
- when children are showing evidence of being subject to maltreatment, with associated parental mental health, substance abuse, or conflict
The Health Inequity group have asserted that ‘reducing ACEs would have a significant impact on harmful responses associated with ACEs’ – reducing early sex, unintended pregnancy, smoking, binge drinking, cannabis use, heroin crack use, violence victimisation, and perpetration, incarceration and poor diet. Whilst there is an extensive literature associated with modifying the impact of abuse and neglect, there are limited studies which focused on ACEs. The studies so far have all focused on children under five years of age.
A Parallel development to the development of the ACEs concept has been the introduction of the ‘The Framework for the Assessment of Children in Need and their Families (the ‘Assessment Framework ‘This was introduced as part of the process of enlarging the field of vision of professionals concerned with children in need of services, as well as in need of protection. This eco-systemic framework provides a conceptual map to help professionals consider the child’s functioning and needs, the capacity of parents to provide for those needs, the way their needs were being met (or not) and the role of family and environmental factors on the child or the parenting capacity of their caregivers. The ACEs risk index can be mapped onto the framework.
Adverse Childhood Experiences -Adverse Community Environments, Climate Change, the Internet, and refugee asylum seekers
Recent research has seen a striking change of focus to enlarge the spectrum of adverse childhood experiences. Ellis and Dietz in 2017 introduced a framework to address ACEs by describing ACEs in the context of Adverse Community Environments, a model which can be extended to include the impact of climate change and the Pandemic as potentially adverse experience. Michael Marmot’s UC Health Team (Allen and Donkin, 2015) noted in an extensive review of the prevalence of ACEs across communities, that those cwith the highest index of deprivation also had the highest incidence of individual ACEs.
There has been universal concern about ‘The covid pandemic as an Adverse Experience’ which has affected whole populations. There have been enormous economic and social shifts. Families have been living in virtual confinement coupled with massive economic disarray. There has been an increase in Domestic Violence and Substance Misuse. These are ideal conditions for a rise in children’s experience of abuse and neglect, with the reduction of contacts with those in the outside world who would see and identify harmful incidents
With increasing concern about ‘Climate Changes as a significant Environmental Adversity ‘‘Lawrence et al. (2021) from the Institute of global health innovation – Grantham Institute have described the environmental adversity as climate changes manifested as – Heat and droughts, wildfires, smoke, storms and flooding, rising sea levels, associated with negative mental health and emotional wellbeing of people around the world.
Learning online and developing a wide range of IT skills is now the norm for many children in Western society. There are potential substantial benefits for all children and particularly those with special needs. Acquiring online skills, including competence at certain video games, may have offline social and educational benefits. However, the online world is not always a positive and safe environment for children, there can be Exposure to harmful influences online since potential predators are also online, seeking access to victims of all ages, there are risks of children being groomed for abuse. There is potential for children and young people to abuse other children and young people, cyber-bullying, attacking, and excluding which can trigger and maintain traumatic responses, associated with self-harm and suicidal responses
The University team in Bangor have gathered the evidence together to demonstrate the significant level of ACEs in child refugees and asylum-seeking populations. In addition to ACEs within the home or family, are added the set of ACEs pre-migration – destruction, deprivation, witnessing and experiencing violence, during the migration journey, and post-migration. This is an example of taking a highly stressful context for children and young people, understanding the adversities children and young people might experience, to assist practitioners helping children and young people process those experiences and develop resilience and coping
Studying ACEs directly in Childhood Directly
Finkelhor et al. (2012) pointed out that much of the original research focused on retrospective information and was limited to the Classic Ten Adverse Experiences. Predictors missing from the ACE study model were peer rejection, exposure to violence outside the family, low socio- economic status, and poor academic performance. Using an adapted form of their Juvenile Victimisation Questionnaire, Finkelhor et al. added to the original ACEs form. Subsequently Heather Turner working with David Finkelhor described 40 forms of Adverse Experiences which better predicted traumatic responses in childhood. These ACEs were derived from their epidemiological research on adversities experienced
during childhood. Exposure to multiple adversity from early childhood to middle childhood, and adolescence represents cumulative trauma exposure which is associated with higher scores – Internalizing, Externalizing, and PTSD symptoms. Juvenile offenders are more likely to have associations with four or more ACEs than general study populations. Life-time adversities include maltreatment, emotional and sexual abuse, witnessing violence, parental mental health, and residential instability, separation are associated with mental health problems in adolescence – long-standing traumatic symptoms, self -harming responses, attachment disorganisation.
A core dimension of ACEs is neglectful care associated with many forms of adversity. When combined with threat there is a significant cumulative impact. The impact of neglect and emotional maltreatment on the developing child is less recognised than the impact of other types of abuse despite neglect being the most ‘challenging and prevalent’ form of abuse
Twenty Years of ACEs Research – What have we learnt
ACEs are associated with a range of poor health outcomes. Those individuals who had experienced at least 4 recorded ACEs reported an increased risk of poor health outcomes:
- modest – physical inactivity, overweight, obese, diabetes
- moderate – smoking, heavy alcohol use, cancer, heart disease, and respiratory disease
- strong for sexual risk taking, mental ill health, and problematic alcohol use
- strongest for problematic drug use and interpersonal and self-directed violence
- strong for sexual risk-taking, problematic alcohol use, strongest for problematic drug use, interpersonal and self -directed violence.
It has been estimated that the annual health costs associated with ACEs were US$581 billion in Europe (equivalent to 2·67% of gross domestic product) and $748 billion in north America (equivalent to 3·55% of gross domestic product). Researchers have identified protective factors which could mitigate against poor health outcomes associated with high levels of ACEs. The Bellis Team described the protective value of community assets included – networking opportunities and settings to build friendships; being treated fairly; having supportive childhood friends, being given opportunities to use abilities; having a trusted adult, having someone to look up to. A variety of individual, family and community factors are now being identified. These factors help explain why although the ACEs score was simple to understand and carry out, with strong, statistically significant associations with outcome at a population level, an ACEs score does not predict the outcomes for the individual. It should not be relied upon as a sole measure in assessments with the individual child and family. A further imitation is that the ACEs score assumes that each adversity has the same association with outcomes of interest – which may not be the case (e.g., sexual abuse may affect children differently to parental separation). Longitudinal research is now being conducted balancing risk and protective factors to develop a risk calculator which identifies more accurately which children exposed to ACEs will develop poor health outcomes. The complex overlapping mental health responses which result have also been identified – Multivariate Risk/Resilience Predictors were established gathered from recorded experiences during the child or young person’s regular reviews:
- Individual characteristics: Sex, intelligence, personality factors, openness, conscientiousness, extraversion, agreeableness neuroticism
- Mental health was recorded during development: ADHD symptoms, conduct disorder, anxiety, depression, self-harm, psychotic symptoms
- Family and Community Factors – maternal warmth, sibling warmth, family psychopathology, socio-economic circumstances, community crime, victimisation, social cohesion, status among peers
Given the growing awareness of the complexity of factors which are associated with understanding the harmful impact of adverse childhood experiences, we need to consider a complex response.!! The majority of interventions have a single focus, an alternative is the application of Modular approaches, developed to meet the treatment needs of children and young people with a range of overlapping mental health problems The approach capitalizes on the knowledge embedded in evidence-based treatments for mental health, distilling Common Practice Elements from across the field of intervention, creating a library of evidence based interventions which could fit the complex needs of children young people and their families. The development of the Hope For Children and Families Resources added common practice elements from effective interventions to treat single forms of maltreatment, and integrated them into a series of Intervention manuals. This approach will be presented in a series of four Child Adversity: Recovery, Resilience and Prevention Seminars in May.
The key goal of the ACEs Special Interest Group
Van IJzendoorn et al.’ (2020) umbrella synthesis of meta-analyses of child maltreatment antecedents and interventions concluded that there was now good evidence to identify parental risk factors for maltreatment and adversity. These risk factors include parents who have themselves been victims of child maltreatment, been subjected to interpersonal violence, had negative personality attributes associated with mental health disorders, and have limited social and material resources.
However, they noted there was a “‘power failure’ of interventions to prevent or decrease child abuse and neglect in the next generation” They concluded “the scarcity of evidence-based means to break the circle of maltreatment is deplorable. Child maltreatment is a widespread global phenomenon affecting the lives of millions of children all over the world, which is a betrayal of the United Nations Convention on the Rights of the Child (United Nations, 1989)” (p. 284).
Through our mission to help integrate and to develop research, and critical understanding of the complex nature of adversity in childhood, formulated as Adverse Childhood Experiences and the implications for practitioners across services for children and young people we hope we can begin to to make a difference.
You can join via the ACAMH website.