More evidence needed on adverse childhood experiences approach

Within its new report, the Early Intervention Foundation (EIF) says public services may be taking ‘significant risks’ by being overly focused on the ten ACEs.

The ACEs framework is a set of ten traumatic childhood circumstances (see box) which are consistently shown to increase the risk of mental health problems, chronic diseases and involvement in crime later in life.

An American study of the framework found that those who reported four or more ACEs had an increased risk of poorer longer-term health and social outcomes.

Evidence gaps

While the EIF acknowledges that ACEs have been useful for raising awareness and galvanising action, it says there is a risk of ‘oversimplification’ and finds that there are major gaps in the evidence on how to identify and support the most vulnerable children.

Its report, Adverse childhood experiences: What we know, what we don’t know, and what should happen next, finds that many other adversities in childhood, beyond the ten ACEs, also increase the risk of serious adult problems. They include:

• Economic disadvantage.
• Low birth weight – found to increase the risk of having a stroke before the age of 50.
• Disability – increases the risk of problematic drinking in adults by over 80 per cent.
• Bullying during the teenage years – increases the risk of an adult mental health problem by more than 50 per cent.
• Childhood experiences of social discrimination – found to increase the risk of adult mental health problems.

It says that a focus on just the ten ACEs risks missing many children who need help as much or more than those currently being identified.

The EIF also raises concerns about some practices based on the ACEs framework. It says ACE screening or routine enquiry are increasingly being used to identify children, but few evaluations have ‘rigorously’ tested whether ACE screening is an effective method for identifying vulnerable children and making treatment decisions.

Dr Kirsten Asmussen, lead author of the report and head of ‘what works, child development’ at EIF, explained, ‘Our research shows that it’s clear that ACEs themselves are harmful and must be stopped. However, the evidence supporting some of the assumptions about ACEs is less clear. This includes the claim that ACEs are the root cause of many life-threatening diseases. The truth is, the best evidence does not fully substantiate this claim.

‘More research is needed to understand whether ACE screening is actually helpful or might just make things worse.’

Recommendations

The report calls for more data and evidence to be collected, and says with this it will be possible for public services to put in place better ways of identifying and supporting those affected by childhood adversity.

The EIF recommends a wider, whole-system approach, which includes:

• National and local policies to address the wider social and economic conditions that can increase the likelihood of children being exposed to adversity, such as poverty and community crime.
• Strengthening local systems for preventing childhood adversity and developing the skills so practitioners can support families.
• Significantly investing into research on childhood adversity, including the rigorous evaluation of a comprehensive public health response to tackling adversity.

Views of the sector

Independent consultant Anne O’Connor of Primed for Life, who like the EIF believes there are more potential ACEs than ten, warned against the complete dismissal of the framework as it has been helpful in raising awareness of a significant issue.

She explained, ‘In discussion with practitioners I tend to explore the fact that there are likely many more potential ACEs than ten and that they can be seen across all socio-economic sectors. Also, the likelihood of a genetic predisposition towards greater resilience as well as the benefits of experience that helps buffer the effects – the most significant of these being positive relationships.

‘However, for me, the ACEs/developmental trauma/attachment awareness terminology has been helpful in raising awareness of a significant issue in society today that can help provide another useful lens to view behaviour and later issues with self-regulation. But like with so many aspects of our work with families and young children, it is more complex than soundbites and new terminology.’

She added, ‘Unfortunately there is always a desire for a “quick fix” and then an outcry when people grasp too firmly to it rather than use new information as a stepping stone to a continually growing greater awareness and understanding.

‘The EIF’s report confirms the need for greater and broader awareness-raising and training. The Department for Education’s cavalier and ill-informed grasping of “attachment” as Early Learning Goal material is evidence of just how easily this information can be misused.’

Bryony Monaghan, service manager for additional special needs and well-being at Stirling Council, told Nursery World that the approach has its limits.

She said, ‘ACEs has recently been a significant narrative in Scotland – gaining interest through social media and events. Initially there was overenthusiasm for it, but now that has become more measured.

‘While the approach has the potential to change policy direction, practically it has its limits. The roots for this research are American so they don’t cover all areas of adversity, including poverty, which is a big consideration in Scotland.|
‘However, the ACEs approach has raised awareness around challenging behaviours and unequal life chances.

‘For us, we focus on the nurture principles, which involves understanding and addressing children’s needs. Children’s behaviour is understood as communication and not a problem. It’s about more appropriately supporting children and focusing on the power of relationships, and understanding that change is possible.’

What are the 10 ACEs?

• 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
  in prison
• Parental separation or divorce on account of relationship problem