The concept of ACEs- Adverse Childhood Experiences and their effects upon later adult life- is becoming a much discussed meme across the western world. It is therefore now time to reflect upon these ideas and to consider their validity, particularly within practice environments. This blog will consider ACEs in this spotlight, arguing that the concept has a clear relevance and application for practice with children and families going forward into the twenty first century, although there are clear pitfalls which must be carefully avoided when putting the ideas into practice. The basic ACEs theory is demonstrated in the following diagram:
The original study to explore the concept of ACEs was that of Felitti et al in 1998. The researchers carried out a large-scale analysis of the effects of a range of childhood stressors upon both mental and physical health in later life and found a number of statistically significant effects. Film maker James Redford, son of actor Robert Redford, came across an article disseminating the research findings and thought these ideas should be raised more prominently within the public eye (Cocozza 2017) In order to achieve this he made a film entitled Resilience: the biology of stress and the science of hope which has now been widely distributed across the western world.
Redford compares the constant stress that some children live under as comparable to arriving home every night to find a bear in the living room; that the mentally ill or abusive parent and/or the effects of ongoing poverty upon the family are likely to have long term adverse effects: ‘day after day, those chemicals – the adrenaline, cortisol, the process of high sugar, that whole response, changes the way your brain processes information. It affects the development of the organs on a cellular level. This continual exposure to stress wears the body down’ (Cocozza 2017, online).
ACEs research has continued across the world, making very similar findings to Felliti et al (1998). Recent large-scale studies in Wales (Bellis et al 2015) and Scotland (Couper and Mackie 2016) have linked poor mental and physical health in adulthood to childhood ACEs, while clear links have been drawn between ACEs, poverty and parenting stress (Steele et al 2016). Of course, human beings are the sum of all their experiences, which makes isolating cause and effect extremely difficult. A recent development has been the suggestion of a 'pair of ACEs', encompassing the environmental aspect. This was recently explored by NHS (Highland) in their Annual Report of 2018.
Such a vast number of variables in individual experience have been raised by those criticising the ACEs concept, who propose that, by over-simplification, there may be the creation of a deficiency model and a subsequent self-fulfilling prophecy, depicting individuals simplistically as victims of circumstance. The implication emergent from such a construction may be that people have little ability to control their own destinies, leading to stereotyping and stigma (Edwards et al., 2017). These researchers also express concerns about the problem of simplistic tick box screening being developed by amateurs, which may subsequently be used to promote shallow concepts of building resilience through counselling, rather than exploring solutions to the root causes.
These are of course highly valid concerns, but at the level of how we as a society respond to the concept of ACEs, rather than whether the effects actually exist or not. It is however useful to note that the practice of simplistic screening leading to self fulfilling prophecies must certainly be stringently avoided as a more ACEs aware society develops.
Edwards et al.’s more far reaching criticism- that ACEs is a retrospective model based on adults’ recall of childhood events, and may therefore lack reliability and validity (2017) is partially countered by the findings of Barboza Solis et al (2015) who found evidence of ACEs effects in the 1958 British birth cohort study, and by Horowitz et al (2001) who created a sample of participants from records of those who had experienced childhood adversity, and thence exploring whether ACEs were a factor in their adult lives. Both studies found evidence of ACEs effects, and additionally that later life events and gender were also significant influencing factors. Dube et al (2003) found evidence of ACEs effects in a US study dating back to participants born in the early 1900s. They concluded that although ‘ACEs rarely occur in isolation...it has been shown that the limbic system, which is responsible for emotional response, is adversely affected’ (p.274).
People with significant ACE loads, having experienced toxic stress in childhood, enter adulthood with a stress ‘thermostat’ that is chronically set at too high a level, in the same manner as a central heating system that has been set at maximum heat, which puts constant pressure on the boiler, so that when the thermostat is advanced even further by stressors in the day-to-day environment, the system becomes increasingly likely to ‘blow’, see diagram below.
The effect of the stress in early childhood through disruption of the human attachment process has also been extensively studied. Neurobiologists have investigated potential dysfunctions in the limbic system created by the modern practice of placing young infants in mass daycare settings for very long hours. I have carried out a literature review on this area of research, which is currently under peer review. In this I propose on the basis of my findings that as a society we should urgently explore more creative care initiatives for under 3s. In an earlier blog, I reflected that there is much for nations such as the UK to address, for example, the fact that ‘nearly one in three children live in families that are officially designated poor [and] where there is little financial or social support specifically targeted at families with children under three.’ I also consider the problems with memory and learning by cortisol disturbance, such as a short attention span and problems with concentration.
Links have additionally been drawn between adult attachment anxiety and cortisol dysfunction (Quirin et al 2008) and between ‘toxic stress’ and cortisol dysfunction (Oral et al 2015). Burke Harris (2018 p.187) reflects that it is a far more challenging prospect to build healthy attachment relationships and carry out calm, focused nurturing in families who are coping with poverty. It is becoming increasingly clear that categories of ACEs will continue to be refined as the effects are more widely studied, and that we will become more intricately aware of some of the more insidious effects of everyday stressors such as poverty and infant attachment disturbances
Some of these more subtle and transactional effects are already emerging from ACEs research, particularly with respect to attachment. Tharner (2011, p.162) found that ‘parenting stress explained the most variance in child emotional and behaviour problems’ but that ‘in families with high parenting stress securely attached children had fewer socio-emotional problems than insecurely attached children’. Shonkoff et al (2015) found that even just one supportive adult-child relationship in early childhood could blunt the impact of ACEs. These researchers propose that ‘resilience requires relationships’ (p.7) and that it can be strengthened by relationships at any point in childhood. Their checklist of important protective factors is illustrated in the following diagram.
Finally, it is important to remember that ACEs tend to be passed from generation to generation if parents do not receive support to reflect upon childhood stressors, and to explore how these may feed into current problematic behaviours and ongoing health issues. The aim of working with adults with high ACE scores should therefore be to help them to understand how their body and brain have been primed by their childhood environment. Just as we must guard against shallow screening exercises that label and ‘victimise’ children, so we must guard against doing the same thing to their parents. As Burke Harris (2018, p.219) points out, ‘how adversity affects you is not a referendum on your character. We don’t need to play the shame game.’ Support for parents with high ACE scores is currently being trialled.
For example, Blair et al.,(2019) studied the effects of ‘Parent-Child Interaction Therapy (PCIT)’ which compared families where parents were carrying a range of emotional stressors from their own childhoods to those who were not, indicated by scores on the Adverse Childhood Experiences Questionnaire (Felitti et al., 1998). They found that parents with a high ‘ACEs’ score (4 or over) reported significant improvements in the child’s behaviour following PCIT. Thomas et al., (2018) investigated whether pre-natal social support offered to mothers reduced their biological stress reactions and whether any positive effect was then transmitted to the child. They found that this practice reduced biological stress markers in both mother and child.
Of course, the ultimate aim for ACEs informed practice is to create a society in which ACEs occur far less frequently, and where they do, the child and the family are offered support at the earliest opportunity. Will this be very expensive for the nation? Most certainly. But in the end in such a society, taxpayers will not be required to contribute so much to adult health, social care and criminal justice systems, spending less on average on each individual over a ‘whole life’ basis. And of course, far more of the population will have an experience of life that is far more pleasant than they do at the moment. The answer to those who propose that we cannot afford to address ACEs on a national scale is that what we actually cannot afford is to continue to sleepwalk into a society that is incrementally losing connection to human emotional needs.
In April 2018, I worked with three other Leeds-based early years professionals to host a showing of Resilience at the Leeds Vue Cinema, in The Light. Initially we were concerned that we would not manage to secure the 30 ticket purchases we needed to fund the film showing. We advertised the event on social media and through our personal contacts, and the ticket sales quickly took off. The cinema kept moving the viewing to bigger and bigger screening rooms, and by the week before the viewing, we had sold all 175 tickets available.
The film was screened to a packed cinema of children’s workforce professionals. We asked people to fill in an anonymous feedback slip on the film, and to state their professional role. When we collated the information from the slips we found that we had attendees from the fields of teaching (primary secondary and university), social work, educational psychology, child and adolescent mental health services, students on child and family related programmes and early years education and care professionals working across the statutory and voluntary/independent sector. The feedback from the attendees made the following overall points:
We can collectively make a change'
'Everybody can play a part'
'It's not hopeless'
'ACEs affect everyone'
‘The world needs to change'
'Spread the word'
'Parent power'
The future for ACE aware practice would seem to be optimistic, although as detailed above, care must be taken to navigate the inherent problems that arise in the use of ACEs in services for children and families. This primarily centres around well-meaning but poorly informed applications of the ACEs questionnaire by people with insufficient training in the relevant area, which, in the worst scenarios, can increase distress rather than alleviating it. The goal should always be to nurture strong attachment relationships between parents and children rather than engaging in ‘parent blaming’, and to support the development of restorative, ACEs aware practices in education, youth work and youth justice.
References
Barboza Solis, B., Kelly-Irving, M., Fantin, R., Darnaudery, M. Torriusani, J., Lang, T. And Delpierre, C. (2015) Adverse Childhood Experiences and physiological wear-and-tear in midlife: findings from the 1958 British birth cohort. Proceedings of the National Academy of Sciences (USA). Available at: http://www.pnas.org/content/early/2015/01/27/1417325112 Accessed 25th April 2018.
Bellis, M., Ashton, K., Hughes, K., Ford, K., Bishop, J. and Paranjothy, P. (2015) Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Cardiff: Public Health Wales. Available at: http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf Accessed on 25th April 2018.
Blair, K. Topitzes, J. and Mersky, J. (2019) Do Parents’ Adverse Childhood Experiences Influence Treatment Responses to Parent-Child Interaction Therapy? An exploratory Study with a Child Welfare Sample, Child & Family Behavior Therapy, 41:2, 73-83, DOI:10.1080/07317107.2019.1599255
Bloom, S. (1995) Creating sanctuary in the school. Journal for a Just and Caring Education Vol 1(4): pp.403-433. Available at: http://www.sanctuaryweb.com/Portals/0/Bloom%20Pubs/1995%20Bloom%20Sanctuary%20in%20the%20Classroom.pdf Accessed on 25th April 2018.
Burke Harris, N. (2018) The Deepest Well: healing the long-term effects of childhood adversity. London: Bluebird.
Cocozza, P. (2017) How childhood stress can knock 20 Years off your life. The Guardian Online. Available at: https://www.theguardian.com/lifeandstyle/2017/apr/29/how-bad-parenting-can-knock-20-years-off-your-life Accessed 25th April 2018.
Coupar, S. and Mackie, P. (2016) Polishing the diamonds: addressing Adverse Childhood Experiences in Scotland. Glasgow: Public Health Scotland. Available at: https://www.scotphn.net/wp-content/uploads/2016/06/2016_05_26-ACE-Report-Final-AF.pdf Accessed 25th April 2018.
Dube, S., Felitti, V., Dong, M., Giles, W. and Anda, R. (2003) The impact of Adverse Childhood Experiences on health problems: evidence from four birth cohorts dating back to 1900. Preventative Medicine Vol 37, pp.268-277.
Edwards, R., Gillies, V., Lee, E., Macvarish, J. White, S. and Walsall, D. (2017) The problem with ACEs. Submission to the House of Commons Science and Technology Committee Enquiry into the evidence base for early years intervention (EY100039). Available at: https://blogs.kent.ac.uk/parentingculturestudies/files/2018/01/Discussing-the-Problem-with-ACEs.pdf Accessed on 25th April 2018.
Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M. and Marks, J. (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults (The Adverse Childhood Experiences (ACE) study. American Journal of Preventative Medicine Vol 14 (4), pp.245-258.
Horowitz, A,. Spatz Widom, C.,McLaughlin, J. and Raskin White, H. (2001) The impact of childhood abuse and neglect on adult mental health: a prospective study. Journal of Health and Social Behaviour. Vol 42(2), pp.184-201.
Jarvis, P. (2014) Some reflections upon infancy in the 21st Century. Mothers at Home Matter. Available at: http://mothersathomematter.co.uk/archives/1512 Accessed 25th April 2018.
Jarvis, P. (2016) Mum’s the word for Theresa, Jeremy and Owen. The Huffington Post. Available at: https://www.huffingtonpost.co.uk/pam-jarvis/mums-the-word-for-theresa_b_11674502.html Accessed 25th April 2018.
Jarvis, P. (2017) Banish Baseline, beat poverty instead. Leeds Trinity University Blog. Available at: http://www.leedstrinity.ac.uk/blogs/Banish-Baseline-Beat-Poverty-instead Accessed 25th April 2018.
Oral, R., Ramirez, M. Coohey, C., Nakada, S. Walz, A., Kuntz, A., Benoit, J. and Peek-Asa, C. (2015) Adverse Childhood Experiences and trauma informed care: the future of health care. Pediatric Research. Vol 79 (1) pp.227-233.
Quirin, M., Prusessner., J. and Kuhl, J. (2008) HPA system regulation and adult attachment anxiety: individual differences in reactive and awakening cortisol. Psychoneurology. Vol 33, pp.581-590.
Shonkoff, J., Levitt, P., Bunge, S., Cameron, J., Duncan, G., Fisher, P., Fox, N., Gunnar, M., Hensch, T., Martinez, F., Mayes, L., McEwen, B. and Nelson, C. Supportive relationships and active skill building strengthen the foundations of resilience. National Scientific Council on the Developing Child. Harvard: Center for the Developing Child, Harvard University. Available at: https://developingchild.harvard.edu/wp-content/uploads/2015/05/The-Science-of-Resilience.pdf Accessed on 25th April 2018.
Steele, M., Knafo, H., Meissner, P. and Murphy, A. (2016) Adverse Childhood Experiences, poverty and parenting stress. Canadian Journal of Behavioural Science. Vol 48(1), pp.32-38.
Tharner, A. (2011) Parents and Infants: determinants of attachment in a longitudinal population-based study. Amsterdam: Erasmus Medical Centre.
Thomas, J, Letourneau, N. Campbell, T. and Giesbrecht, G. 2018. Social buffering of the maternal and infant HPA axes: Mediation and moderation in the intergenerational transmission of adverse childhood experiences. Development and Psychopathology 30, 921–939
Pictures 1-5 supplied by 70/30 Campaign http://www.70-30.org.uk/infographics/
Picture 6, Author's own.