Adverse Childhood Experiences (ACEs) Special Interest Group

Boy with his head in his arms

ACE’s Special Interest Group – A Special Interest Group (SIG) established by ACAMH with representatives from related organisations, to help integrate and develop research and critical understanding of the complex nature of Adversity in Childhood, formulated as ‘Adverse Childhood Experiences – ACEs’ and the implication for practitioners across services for children and young people.

Mission statement

  1. The ACEs SIG will review research and will critically reflect on the way adversity in childhood is associated with developments across the life-cycle, through circulation and discussion of research papers. This will introduce members of the SIG to key current thinking, e.g. the growing literature from longitudinal studies.
  2. Journal meetings – Discussion on specific papers presented by the authors and a panel of experts, including service users sharing lived experiences. Participation by those attending would be via Qs and As, and responses to those whose questions were not responded to would be answered through a recording by the author. Journal meetings would be planned bi-monthly.
  3. Publications from the UK Trauma Council could be made available – e.g. the recent material on ACEs, Traumatic Bereavement, and relevant material which focuses on the pandemic as a highly significant Adverse Childhood Experience.
  4. Preparation of training material e.g. different approaches to measuring ACEs in children and young people; ACEs in particular populations, e.g. ACEs associated with Refugee and Asylum Seeking children and young people; ACEs associated with Offending Behaviour; ACEs associated with Looked After Children; ACEs and Parenting; different models introducing Trauma Informed Care.
  5. Policy Information – Government Policy information in the context of ACEs through liaison with Stephanie Lewis who is working on this theme for ACAMH.

Joining the SIG

[application form goes here]

Discussion forum

[Join the chat link goes here].

Ground rules

By using this forum, you agree to the following Ground Rules for conduct:

  • Use respectful and appropriate language at all times
  • You must respect copyright laws
  • Please stay on-topic;  start a new thread if you want to take a discussion in a new direction
  • Please do not use the forum for content that is not relevant to the mission statement of the ACEs SIG
  • Any content which does not abide by these rules may be removed without warning.

Events and Meetings

Panel discussion on priorities for future research

Thursday 10th March at 2pm, 2022

A virtual panel discussion is planned to discuss priorities for future research on ACEs, from a range of non-academic perspectives.

We have secured speakers from the NSPCC, Early Intervention Foundation, and the Trauma, Adverse Childhood Experiences & Resilience Unit from the Scottish Government. We hope to also have a service user join

Further details will be announced – please mark your diaries.

  • How are ACEs defined - The cycle of ACEs

    The wider maltreatment context around ACEs

    Maltreatment has been increasingly recognised over past decades including the emergence of different types of child abuse.

    A recent review outlines the historical, social and research contexts in which ACEs emerged from the extensive maltreatment literature. The current political and financial implications for practice and research are discussed (Vizard, Gray & Bentovim, 2021, p.1, p.9)

    Definition of ACEs in Felitti et al.’s 1998 study

    Vincent Felliti and his colleagues at the Kaiser Permanente Organisation (1998) defined Adverse Childhood Experiences as follows:

    Ten Adverse Childhood Experiences – The ‘Classic ACEs Profile’

    1. Physical neglect: failure to supervise or provide for the child
    2. Emotional neglect: caregiver unable to express affection or love for the child due to personal problems
    3. Physical abuse: severe assault or physical abuse such as shaking or hitting
    4. Sexual abuse: child experienced sexual abuse or forced sex
    5. Emotional abuse: caregiver engaged in psychological aggression towards the child such as threatening
    6. Caregiver treated violently: domestic violence of an adult in the home including slapping hitting or kicking
    7. Caregiver substance-abuse: active alcohol and drug abuse by a caregiver
    8. Caregiver mental illness: serious mental illness or elevated mental health symptoms
    9. Caregiver divorce/family separation: child’s parent(s) deceased, separated or divorced or child was abandoned or placed in out of home care
    10. Caregiver incarceration: caregiver spent time in prison or is currently in jail or detention centre

    What was unique in Fellitti et al.’s approach was that they established an “ACE score” by summing the number of ACEs reported by more than 17000 adults in the USA. The study showed that the higher the ACE score, the stronger the association was with poor subsequent health as adults, and the greater their risks of health-harming behaviours heart disease, cancer, stroke, type 2 diabetes, chronic bronchitis, fractures, hepatitis and poor self-rated health.

    Current definition of ACEs

    ACEs are defined as experiences which require significant adaptation by the developing child in terms of psychological, social and neurodevelopmental systems, and which are outside of the normal expected environment (adapted from (McLaughlin, 2016). ACEs may include other adversities not included in Felitti et al.’s 1998 study, such as bullying victimisation, parental death, and community violence.

    The cycle of ACEs

    ACEs cycle

    Shanta Dube recently described the cycle of ACEs (Dube 2020):

    • Childhood adversity – abuse, neglect, and stressors in the home
    • Adolescent outcomes – associated with substance use, suicidality, mental health, early pregnancy, substance misuse, and sexually harmful behaviour and exploitation
    • Adult outcomes, associated with chronic diseases, substance use, obesity, STD/HIV risk, sexual risk behaviour, mental health, suicidality, emotional dysregulation
    • Impact on Parenting – The cycle is completed through the association with harmful parenting which completes the cycle.

    References

    Dube S (2020). Twenty years and counting – the past, present and future of ACEs Research, in G. Asmundsen and T Afifie (eds). Adverse Childhood experiences. Academic Press.

    Felitti V.J. Anda R.J et al (1998). Child Abuse and Household dysfunction and adverse health impact ACE. Am J Preventitive Med, 14: 245-258.

    McLaughlin K et al (2016). Maltreatment Exposure, and the long shadow of adverse childhood experiences. Psychological Science Agenda.

    Vizard, E., Gray, J., & Bentovim, A. (2021). The impact of child maltreatment on the mental and physical health of child victims: A review of the evidence. BJPsych Advances, 1-11. doi:10.1192/bja.2021.10.

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  • ACEs and applications to research, clinical work, public policy and public health

    The structure and function of an ACEs hub

     

    ACEs hub diagram

    Twenty year Review

    Rebeca Lacey and Helen Minnis in their 20 year review of ACEs noted Adverse childhood experience scores have been instrumental in stimulating an explosion of transformative research into childhood adversity.  Innovations in practice are multiplying based on these findings.

    1 ACEs Trauma -informed practice

    Based on the evidence of potential harmful impact of ACEs, Hughes et al (2017) argue that ACE 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.
    • a programme of routine enquiry concerning the presence of ACEs has been advocated (REAch) (McGee et al., 2015 to enable identification of need and early intervention or access to services. Routine enquiry has been established in the State of California

    2. Public Policy approaches

    ACEs awareness promotion – data from population studies has increased public awareness, Trauma –Informed Training of front- line staff – helps staff understand ’what has happened’ and consequences, with a resulting compassionate workforce, early intervention, integrated and collaborative services.

    Services have come together to develop a community response.  Integrated ACEs hubs have been developed in Scotland and Wales, and across a number of states in the US. Authorities across the UK are considering the need to develop a Trauma Informed Approach to planning and delivering services to children, young people and their families. These include children who are abused and neglected, sexually exploited, refugees, looked after, and those who have offended.

    There is limited research to date on the effectiveness of these approaches.

    3  The effects of reducing ACEs – Health Equity

    Reducing ACEs

    The Health Inequity group ( Allen and Donkin above ) based on the incidence studies of Bellis have estimated that reducing ACEs would have a significant impact – reducing early sex, unintended pregnancy, smoking, binge drinking, cannabis use, heroin crack use, violence victimisation, and perpetration, incarceration and poor diet.

    4. Strengths and limitations of the ACEs score.

    It has become evident that the ACEs score used extensively in research studies is basically a risk index . Rebecca Lacey and Helen Minnis (2019) pointed out the strengths of ACEs score.  It was simple to understand and carry out, and more likely to find strong, statistically significant associations with outcome, and acknowledges that adversities tend to co-occur.

    However, the scoring procedure assumes each adversity has the same association with outcomes of interest – e.g pervasive- neglect compared to single forms of Physical Abuse or Sexual Abuse. The score is reliant on retrospective reports likely to be biased or unreliable, and many studies focus on adult outcomes rather than child outcomes.

    Jessie Baldwin and colleagues (2020 ), using longitudinal data, reported that ACE scores forecast mean group differences in health, but showed poor accuracy in predicting an individual’s risk of later health problems. They concluded “Targeting interventions based on ACE screening ineffective in preventing poor health outcomes”.

    Lacey and Minnis stated:

    “The challenge now is to find more nuanced ways of measuring and conceptualising ACEs that are still easily usable so that detailed models of development can better inform practice and policy.”

    There is a need to carry out methodologically rigorous studies to build the evidence base of trauma-informed care as a framework and complement to trauma-specific services.

    5. A systematic review of trials to improve child outcomes associated with ACEs

    Marie-Mitchell and Kostolansky, 2019 were able to identify 20 Randomised Control Trials. The studies all focused on children under five years of age. The commonest ACE was parental mental health; there were fewer parent alcohol, substance abuse or domestic violence associated ACEs studied.

    Multicomponent medium- to high-intensity interventions that utilized professional home visitors to provide parenting education or mental health counselling demonstrated the largest effects. There was evidence of reduction of the impact of ACEs and improved parent-child relationships.

    However, there was no research which included children older than 6 years of age, or on improving child outcomes for other ACEs.

    6. Research on risk and resilience factors

    Meehan and colleagues (2020) and Lewis et al (2021) have explored risks, vulnerabilities and resilience factors in their longitudinal study of Twins in the Environmental Risk (E) study. Participants were 2232 twin children born in England and Wales in 1994–1995.

    A subset of the E-Risk Study sample exposed to any type of severe victimization during childhood was studied:

    • Exposure to victimization was assessed at 5, 7, 10, and 12 years of age.
    • Cumulative information exposure to domestic violence; frequent bullying by peers; physical abuse sexual abuse; emotional abuse and neglect; and physical neglect
    • Non-complex traumas a one-off assault, an accident and learning about the sudden death of a parent.

    Multivariate Risk/Resilience Predictors:

    • Individual: Sex, Intelligence, personality factors, openness, conscientiousness, extraversion, agreeableness neuroticism,
    • Mental Health: ADHD symptoms, conduct disorder, anxiety, depression, self harm, psychotic symptoms,
    • Family and Community maternal warmth, sibling warmth, family psychopathology, socio-economic circumstances, community crime, victimisation, social cohesion, status among peers

    Psychiatric Assessment aged 18
    Chart of psychopatholog risk by ACE

    The figure demonstrates that exposure to trauma during childhood results in a spectrum of mental health responses measured at aged 18:  Post-Traumatic responses, through depression, anxiety, conduct disorder, psychotic symptoms and suicide attempts.

    Complex trauma exposure included multiple events, interpersonal assaults or threats in childhood or adolescence. Repeated child abuse, severe bullying, witnessing neighbourhood violence resulted in more extensive mental health responses

    Conclusions

    This work represents an important development in the field because it demonstrates the complexity of response to exposure to trauma, and how few of the young people received treatment for traumatic responses. The research also demonstrated that taking into account a range of individual, family and community risk, vulnerability and resilience factors could better predict mental health outcomes for the individual factors.  Balancing risk factors represented in the ACEs score with resilience factors could guide the practitioners assessment and intervention.

    References

    Allen M & Donkin A (2015) The impact of adverse experiencesin the home on the health of children and young people, and inequalities in prevalence and effects. Institute of health equity: London, UCL.

    Baldwin J et al (2020). Population vs Individual prediction of poor health from results of Adverse Childhood Screening. JAMA Paediatrics doi;10.1001/5602.

    Hughes K, Bellis MA et al (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health 2: 356–366.

    Lacey R & Minnis H (2019). Practitioner Review: Twenty years of research with adverse childhood experience scores – Advantages, disadvantages and applications to practice. Journal of Child Psychology and Psychiatry, 61(2), 116–130.

    Marie-Mitchell A & Kostolansky R. (2019). A systematic review of trials to improve child outcomes associated with adverse childhood experiences. American Journal of Preventive Medicine 56(5): 756–764.

    Meehan AJ et al (2020). Developing an individualised risk calculator for psychopathology among young people victimised during childhood: a population- representative cohort study, J Affective Disorders 262 90 -98.

    NHS Highlands (2018). Adverse childhood experiences, resilience and trauma informed care: A public health approach to understanding and responding to adversity. Annual Report of the Director of Public Health 2018, NHS Highland.

  • The Hope for Children and Families Modular Programme

    Intervening effectively to modify the harmful impact of ACEs

    The limitations of current intervention approaches to modify the harmful impact of ACE – A recent discussion paper (Bentovim et al 2021)

    Despite the availability of a wide range of effective evidence-based interventions to prevent the harmful effects of adversity, there is limited and patchy use of these interventions to address the needs of individuals who have experienced extensive exposure to ACEs with the complex mental health impacts, and the cumulative harmful impact on the developing child’s mental health and wellbeing.

    Macdonald et al. (2016) comment that Trauma-Focused Cognitive Behavior Therapy is effective for post-traumatic stress disorder, complex trauma, and associated emotional problems. However, “most children experience more than one form of maltreatment, and there is growing recognition of the need to better take into account children’s profiles of maltreatment in order to improve policy and practice” (p. 38).

    The NICE guideline which recommends a set of well-evidenced approaches to modify the impact of maltreatment draws on differing theoretical models and concepts, presents a considerable challenge to planners and commissioners of services who must decide which types of interventions will best address the needs of those in receipt of their services. There are difficulties in how to ‘navigate’ among the different approaches – Psychodynamic, Cognitive Behavioural, and Systemic – to meet the complex needs of the child and family. Implementation is a considerable challenge to planners and commissioners of services. Much of the research on the manuals’ effectiveness has been undertaken in the U.S., and just focuses on single forms of maltreatment.

    The complexity of an individual’s responses to multiple ACEs, therefore, demands a therapeutic approach that can encompass an infinite range of responses.

    How a modular intervention approach may help

    Modular approaches were developed to meet the treatment needs of children and young people with a range of mental health problems (e.g., Chorpita, Daleiden, & Weisz, 2005). A related approach to conceptualizing specific practices in the literature sought ways to capitalize on the knowledge embedded in evidence-based treatments for mental health (e.g., Chorpita & Daleiden, 2009). A structured methodology was developed to map, identify and categorise the common treatment features from 615 treatments in 322 randomized trials. It was possible to distill out the specific practice components of each type of treatment i.e. practice elements from different manuals.

    The Modular Approach for Children with Anxiety, Depression, Trauma and Conduct problems (MATCH-ADTC: Chorpita & Weisz, 2009) is a multi-disorder intervention system that incorporates treatment procedures (elements) and treatment logic (coordination) based on four successful evidence-based interventions for childhood anxiety, depression, trauma, and conduct problems, with modifications allowing the system to operate as a single protocol.

    The Hope for Children and Families Intervention Resources

    Using the methodology described above for developing the MATCH-ADTC, common treatment elements were distilled from across the field of interventions for individual forms of child maltreatment. Twenty-two RCTs were identified for the treatment of different forms of maltreatment (Bentovim & Elliott, 2014). The forty-seven common practice elements that emerged were categorized as focusing on work with children, young people, parents/caregivers and the family as a whole.

    Elements targeting the antecedents of adverse child hood experience include psychoeducation for parents; exploration of the impact and origins of abuse and exposure to violence; addressing parental mental health difficulties; and, learning positive parenting skills.

    The elements targeting work with children and young people include psychoeducation on the impact of their maltreatment; managing and exposing traumatic thoughts and feelings; relaxation; problem-solving; relationship building; and, social skills talent/skill building.

    ACEs framework

    The Framework for the Assessment of Children in Need and their Families was introduced in 2000 (D.H & D.F.E 2000) and was utilised to provide the holistic framework for assessment, analysis and intervention. The framework developed in parallel to the development of ACEs in the UK as a result of the awareness that then current approach to Child Maltreatment focused on abusive action.

    Paralleling Felliti’s introducing the context of harmful adversity, there was a growing awareness of a need to look a holistically at the range of the Child’s developmental needs, the Capacity of parents to meet the developmental needs of the child, and Family and environmental factors associated harmful parenting. As a result, a definition of a Child in Need of Services was developed under Section 17 of the Children Act 1989 and was adopted as a standard for Community Children’s Health and Social Care Services.

    A variety of tools were commissioned to assist practitioners implement the Assessment Framework in practice. This included the development of the Hope for Children and Families Modular Intervention Resources (Bentovim et al 2021) a series of guides which provides a library of interventions which can assist practioners working across services to meet the complex range of responses associated with maltreatment and ACEs. They provide a library of modules which can be integrated into a management plan, establishing collaborative goals, with children and families, and can be adapted for use across services.

    ACEs Hope diagram

    Guides

    Each of the guides is described below.

    Engagement and Goal Setting

    The ‘Engagement and goal setting guide’ (Bentovim et al., 2017) helps practitioners promote a sense of hopefulness, orientates the practitioner and family to the profile of Adverse Childhood Experiences, family strengths and difficulties, and establishes shared goals, and the measures by which outcomes will be monitored.

    Targeting the parental antecedents of maltreatment and ACEs

    Four intervention guides cover different areas of parenting: ‘Promoting positive parenting’ (Roberts, 2016), ‘Promoting children and young people’s health, development and wellbeing’ (Bentovim, 2017a); ‘Promoting attachment, attuned responsiveness and positive emotional relationships’ (Gates & Peters, 2017); and, ‘Modifying abusive and neglectful parenting’ (Bentovim, 2017b). The guides’ modules provide an understanding of the historical and familial stresses associated with ACEs -abusive and neglectful parenting; the impact of abuse and neglect on children’s health and development; interrupting and modifying abusive and neglectful processes, modifying negative perceptions of children, and improving the standard of care. They can be adapted for use with foster, adoptive, and residential caregivers.

    Working with families

    The ‘Working with Families’ intervention guide (Jolliffe, 2016) supports practitioners in their work with families as a group, and in various combinations. This skill helps them to facilitate parent-child communication, and interrupt and find alternatives to conflict within the family, and between the parents and community.

    Direct work with children and young people

    Two intervention guides consider working with children and young people: ‘Addressing emotional and traumatic responses’ (Weeramanthri, 2016); and, ‘Addressing disruptive behaviour’ (Eldridge, 2017). These are core guides for working with children and young people who have been subject to ACEs. These modules help practitioners work with parents and caregivers to develop children and young people’s generic skills to manage their emotions, be safe and develop problem solving abilities. Once basic coping skills have been mastered there are modules for addressing specific anxiety, mood, traumatic responses and disruptive behaviour.

    Working with child sexual abuse

    The ‘Working with child sexual abuse’ guide (Eldridge, 2016) considers working with children and young people who have been abused sexually, their parents/caregivers, and with those who are responsible for or who display harmful sexual behaviour. It is essential that practitioners develop skills to support children and young people who have been exposed to sexual abuse and demonstrate sexually harmful behaviour, often in association with other forms of maltreatment and adversity, and to support their parents.

    Relevance to Child and Adolescent Mental Health

    it is estimated that over 40% of Children and adolescent mental health problems are associated with adversity. These developments represent a significant strand in the field of understanding and intervention in the lives of children and families integrating child, adolescent and adult mental health, and integrating our understanding of developmental and neurobiological processes, and intervention across services. Research in these fields is growing a pace and represents specific areas of development.

    References

    Bentovim A (2017a). Promoting children and young people’s health, development and wellbeing. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Bentovim A (2017b). Modifying abusive and neglectful parenting. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Bentovim A, Chorpita BF et al (2020). The value of a modular, multi-focal, trauma-informed therapeutic approach to preventing child maltreatment: hope for children and families intervention resources. a disruptive innovation. Child Abuse & Neglect 119:104703.

    Bentovim A & Gray J (eds.) (2016; 2017). Hope for children and families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Bentovim A, Gray J, Heasman P & Pizzey S (2017). Engagement and goal setting. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Chorpita BF & Daleiden EL (2009). Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology 77(3): 566–579.

    Chorpita BF & Weisz JR (2009). Modular approach to children with anxiety, depression, trauma and conduct Match-ADTC. Satellite Beach FL: PracticeWise LCC.

    Chorpita BF, Daleiden EL & Weisz JR (2005). Identifying and selecting the common elements of evidence based interventions: A distillation and matching model. Mental Health Services Research 7: 5–20.

    Department of Health, Department for Education and Employment, & Home Office (2000). The framework for the assessment of children in need and their families. London, UK: The Stationery Office.

    Eldridge H (2017). Working with children and young people: Addressing disruptive behaviour. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Gates C & Peters J (2017). Promoting attachment, attuned responsiveness and positive emotional relationships. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Macdonald G, Livingstone N et al (2016). The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: An evidence synthesis. Health Technology Assessment 20(69), 1–508.

    National Institute for Health and Care Excellence. (2017). NICE guideline. Child abuse and neglect.

    Roberts R (2016). Promoting positive parenting. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

    Weeramanthri T (2016). Working with children and young people: Addressing emotional and traumatic responses. In A Bentovim & J Gray (eds.). Hope for Children and Families: Building on strengths, overcoming difficulties. York, UK: Child and Family Training.

  • A Pair of ACEs – Adverse Childhood Experiences, Adverse Community Environments, climate change and the pandemic

    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 experiences.

    Tree diagram of ACEs

    Relationship between ACEs and deprivation

    Michael Marmot’s UC Health Team noted the impact of specific harmful contexts in their study of ACEs deprivation and resulting mental health problems. They also established the increasing rates of ACEs associated with levels of deprivation in the country.

    ACEs by deprivation

    The figure demonstrates respondents describing a range of ACEs – Parental Separation, Domestic Abuse, forms of abuse, alcohol or substance abuse, related to the degree of deprivation in their communities.

    It is striking to note the role of environment stress reinforcing parenting and family stress. Findings also identified in the responses to COVID 19, and the concerns about the impact of austerity as an adverse impact on health and well-being, and the need for community intervention to ‘Build back Better’.

    The Covid-19 pandemic as an Adverse Experience

    • Enormous economic and social shifts. Families in virtual confinement coupled with massive economic disarray, increase in Domestic Violence and substance misuse ideal conditions for a rise in childrens experience of abuse and neglect A recent study (NHS Digital, 2020) of the mental health of children and young people In July 2020 during the COVID-19 pandemic
    • One in six (16.0%) children aged 5 to 16 years were identified as having a probable mental disorder, increasing from one in nine (10.8%) in 2017. The increase was evident in both boys and girls.
    • Higher rate of admissions of younger children to hospital with self-harming behaviour
    • Striking increase in Eating Disorder
    • Increase when parents have mental health problems, family functioning and financial hardships
    • Increase when children have ASD or ADHD

    The impact of climate change on mental health and emotional well-being

    Lawrence et al 2021 Institute of global health innovation – Grantham Institute:

    • Climate changes – Heat and droughts, wildfires, smoke, storms and flooding, rising sea levels, associated is negatively affecting mental health and emotional well -being of people around the world.
    • Increased suicides; severe distress following extreme weather events; provision of care disrupted
    • Distress among young people and ‘eco-anxiety’
    • Exacerbates social inequalities, costs unaccounted, underestimated, and hidden!!

    References

    Afifi T et al (2017). Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse & Neglect 71: 24–31.

    Allen M and Donkin A (2015). The impact of adverse experiencesin the home on the health of children and young people, and inequalities in prevalence and effects. Institute of health equity, UCL.

    Ford T et al (2021). Recent studies of health disorders in children and young people during the pandemic. BMJ 372: n614.

    Lawrence E et al (2021). The impact of climate change on mental health and emotional well-being , implications for policy and practice. Institute of global health innovation – Grantham Institute.

  • Studying ACEs in Childhood Directly

    Increased numbers of Adverse Childhood Experiences, offending behaviour, suicidal ideation and children in foster care.

    1. Direct research with children and young people

    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.

    2. Forty forms of Adverse Experiences

    Subsequently Heather Turner working with David Finkelhor (International Journal of Child Abuse and Neglect, 2020), 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. They also developed screening questionnaires for use with parents for younger children, and questionnaires for use directly with young people.

    The forty Adverse Childhood Experiences (ACEs), were assessed under 11 different conceptual domains, to predict trauma in childhood:

    • Family instability – e.g., divorce homelessness
    • Family disorder – e.g., mental health, drug, alcohol
    • Interpersonal loss – e.g., death, illness, suicide
    • Natural disaster – e.g., fire, flood, pandemics
    • Economic stress – e.g., job loss, welfare
    • Child-maltreatment – e.g., physical, sexual abuse
    • Exposure to community violence
    • Threatened serious assault, racial, homophobia,
    • Physical assault
    • Sexual victimisation – e.g., direct or on-line
    • Peer bullying – e.g., cyber-bullying.

     A different set of 15 items was associated with trauma symptoms for younger (2−9 year-old) compared to older (10−17 year-old) youth.

     Physical and emotional abuse proved important for both age groups.

    However, family-related factors were associated with trauma symptoms in younger children, while community and peer violence exposures were more relevant for older children.

    3. A National Traumatic Stress Survey

    Dierkhising et al. (2019) carried out an analysis of a longitudinal study of health outcomes associated with multiple adversity. They concluded:

    • 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
    • Early childhood adversity is associated with both internalizing and externalizing problems
    • Recent adversity in adolescence, is associated with internalizing problems anxiety and depression in adolescence, and is also associated with self- harming behaviour.

    This research has added to the findings of the association between adversity and mental health responses, noting the differential associations between early and later adversities.

    4.The harmful effects of ACEs associated with children and young people in conflict with the law

    The studies reviewed above have indicated that Externalising Disruptive behaviours are a characteristic response associated with cumulative adversities, and large-scale studies of young people who have been referred for offending behaviour has confirmed the association with ACEs.

    Kaiser graph

    There is a higher prevalence rate of adversity and trauma compared to population studies (Baglivio and Epps et al., 2014; Dierkhising et al., 2013). The figure shows that juvenile offenders are more likely to have associations with four or more ACEs than the study population. These responses may be associated with intellectual disabilities, emotion dysregulation and out-of- control behaviours, antisocial behaviour which is associated with involvement in the criminal justice system (Vizard, 2013; Walsh 2018, p. 18). Vizard also draws attention to the cycle of traumatic effects of a young person’s own sexual or violent behaviour on themselves, on their child victims and on assessing and treating professionals.

    Other findings include.

    • Multiple forms of trauma are more likely
    • Higher ACEs also associated with higher likely of re-offending.
    • There are also protective factors operating which mitigate against the association.
    • The Cambridge longitudinal study (Craiga et al., 2017) noted young people who had been subject to multiple ACEs were less likely to offend if they also had high school attainment, low daring, low hyperactivity, low impulsivity low neuroticism, low dishonesty, and low troublesomeness
    • Those individuals who have a Life-course-persistent antisocial trajectory experienced extensive adversity associated with brain cortex differences.

    5. Suicidal ideation and adversity

    Some of the most concerning situations are young people who self- harm, or display suicidal preoccupations, and suicide attempts. Longitudinal research with young people has explored the association between adversities and subsequent self-harming behaviour.

    The Longscan study (Thompson et al., 2012) notes that cumulative lifetime adversities are associated with teen suicidal ideation. Life-time adversities include maltreatment, emotional and sexual abuse, witnessing violence, parental mental health, and residential instability, separations.

    • Aged 16 each additional ACE led to 11% was associated with likelihood to report self-harm.
    • Recent high adolescent adversity –maltreatment and high peer stress, face to face and cyber-bullying, was also associated with suicidal ideation, poor health, somatic complaints, and any health problem (Carbone et al., 2021).
    • High ACEs – generally were associated with lower educational attainments, depression, smoking drug use and obesity.
    • Girls were significantly more likely to report suicidal ideation than were

    The Avon Longitudinal Study of Parents and Children has been studied to establish predictors of future suicidal and self-harm (Mars et al., 2019) Among participants with suicidal thoughts, they found that the

    ‘ strongest predictors of transition to attempts, – non-suicidal self-harm, cannabis use, other illicit drug use, exposure to self-harm, and higher levels of the personality type intellect/openness. Among participants with non-suicidal self-harm at baseline, the strongest predictors were cannabis use, other illicit drug use, sleep problems, and lower levels of the personality type extraversion’.

    These findings indicate the importance of using longitudinal, prospective studies to establish further understanding between adversity and specific outcomes.

    6. Traumatic experiences of foster care and children and young people

    Research by Lehman et al., (2020) focused on significant adversities reported by children and young people in foster care in Norway.  This is an example of research on a specific population of children and young people in alternative care and examines the association between the complex trauma. Many of these young people were exposed to Post- Traumatic Stress Disorders and Attachment Disorders.

    Traumatic experiences

    Traumatic events

    • Involved in a serious accident – 13%
    • Experienced terror or war 1%
    • Injury, sickness, sudden death of loved ones 54%
    • Experienced bullying or threats 24%
    • Abduction, kidnapping 6%
    • Hit, kicked, pulled, injured, threatened outside family 25%
    • Witnessed others outside family being kicked, pulled, injured, ridiculing, attacking each other 36%
    • Confusion or helplessness 27%
    Any Abuse 36%

    • Witnessing parents or other grown-ups being injured or threatened 16%
    • Kicked, injured, threatened by a parent 18%
    • Being sworn at, offended, and ridiculed 24%

    Any Neglect 36%

    • Cared for a parent 15%
    • Felt unloved, not taken care of, not enough to eat, wearing dirty clothes, caring for siblings 23%

    Any Sexual Abuse 24%

    • Sexual abuse pictures taken 6%
    • Touching, force to touch 13%
    • Attempted intercourse 6%

    Half of the 302 Norwegian children and young people showed symptoms of PTSD, and a significant proportion demonstrated

    • reactive attachment disorders B Type – Low social responsiveness/ emotional dysregulation – significant association
    • DSED – Disinhibited social engagement disorder – significant association

    It was noted there was a similarity in these response to Complex PTSD which is characterised by ‘Disturbances in Self-Organization’ (DSO), dysregulated affects, a negative self-concept, and disturbed relationships. This research extends the growing number of direct research studies exploring potential pathways from adversity to significant psychopathology.

    7. The impact of neglect

    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 (Brassard, 2020), despite neglect being the most ‘challenging and prevalent’ form of abuse (Hibbard, 2020).

    A recent review of systems to protect children from severe disadvantage (Walsh, 2018, p. 20) found childhood abuse, neglect and other ACEs to have been associated with subsequent psychosocial disorders. These include behavioural problems, attention-deficit hyperactivity disorder diagnosis in middle childhood, bipolar disorder, childhood autobiographical memory disturbance, chronic mental health problems, eating disorders, personality disorders, post-traumatic stress disorder, psychosis, self-harm, suicide attempts and uncontrollable anger.

    Associated with neglect is the impact of institutionalisation, and the risk of extreme neglectful care. Although Rutter’s longitudinal review of the ‘spectacular progress’ demonstrated by Romanian orphans adopted in the UK, van IJzendoorn et al. (2020) in their review of the findings associated with institutionalisation associated with severe neglect showed,

    • Attachment difficulties: in the sample of 471 children in 11 studies, a significantly lower proportion of securely attached children (24%) was found in the institution-based children compared with the normative proportion (62%); in addition, there was a much higher rate (57%) of the two most dysregulated types of attachment (insecure-disorganised and unclassifiable) compared with the normative proportion (15%);
    • Delayed physical growth, brain development, cognitive development and attention: within the institutionalised group of children at least 80% were below the mean for the comparisons;
    • A dose–response association: larger developmental delays and atypical development were predicted by longer stays in the institution.

    8. Spanking and adult mental health impairment: The case for the designation of spanking as an Adverse Childhood Experience

    Research on the impact of spanking as a form of discipline has included recommendations of classifying spanking as a significant ACE. This is one element in a world-wide movement to get societies and governments to put a stop to corporal violence and chastisement as a form of disciplining children and to encourage ‘Positive parenting’ techniques.

    Afifi et al. (2017) in a review of the literature on the associated harmful impact of spanking concluded

    • Spanking is defined as “the use of physical force with the intention of causing a child to experience pain, but not injury, to correct or control behaviourbut there is no evidence io its effectiveness!!
    • There are similar responses associated with spanking as those associated with physical and emotional abuse
    • Longitudinal studies indicate Spanking is associated with increased odds of suicide attempts, heavy drinking use of street drug
    • Spanking in childhood is associated with authoritarianism in adulthood, support for punitive public policies

    The specific focus on one form of ACE, and a movement to prevent it represents an example of primary prevention of ACEs.

    Conclusion

    This brief review of the association between ACEs and a variety of situations in children and young people’s lives demonstrates how extensive is their potential influence. It underlines the importance of developing approaches to assessment which builds on the extended range of ACEs described by Finkelhor and colleagues, and also begins to take account of the range of protective influences which mitigate against their associated impact, and to introduce preventative and targeted approaches to mitigate their impact when identified.

    References

    Afifi T et al (2017) Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse & Neglect, 71 (2017)

    Baglivio MT, Epps N et al (2014). The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders. Journal of Juvenile Justice, 3(2): 1–23.

    Brassard MR, Hart SN, Glaser D, et al (2020) Psychological maltreatment: an international challenge to children’s safety and well being. Child Abuse & Neglect, 110(Pt 1): 104611.

    Carbone IT et al (2021). Childhood adversity, Suicidality and Non-Suicidal Self-Injury among children and adolescents admitted to emergency departments. Ann Epidemiol: 33932570

    Craiga J.M., Piquerob A.R, Farrington, D.P. Ttofic M.M., (20170 Adverse childhood experiences and life-course offending in the Cambridge study. Journal of Criminal Justice 2017 53 34 -45

    Dierkhising CB et al (2013). Trauma histories among justice involved youth. European Journal of Psychotraumatology, 4: 20274

    Dierkhising CB et al (2019). Developmental timing of polyvictimisation. Continuity, change and association with adverse outcomes in adolescence. Child Abuse and Neglect, 87: 40 -50

    Finkelhor D, Shattuck A (2012). Improving the adverse childhood experiences study scale. American Journal of Preventative Medicine, 167, 70–75.

    Flaherty, E.G., Thompson, R., Dubowitz, H., Harvey, E.M., English, D.J., Everson, M., Proctor, L.J., & Runyan, D.K. (2013) Adverse childhood experiences and child health in early adolescence. JAMA Pediatrics, 167(7), 622–629

    Ford T et al (2021). Recent studies of health disorders in children and young people during the pandemic. BMJ, 372: n614.

    Hibbard R, Barlow J, McMillan H, et al (2020) Clinical report: psycho- logical maltreatment. Pediatrics, 130: 372–8.

    Lehman S, Breivik K et al (2020). Potentially traumatic events in foster youth, and association with DSM-5 trauma and stressor related symptoms. Child Abuse and Neglect 101: 104374.

    Mars B et al (2019) Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study Lancet Psychiatry 6 327 – 339

    Thompson, R., Litrownik, A.J., Isbell, P., Everson, M.D., English, D.J., Dubowitz, H., Proctor, L.J., & Flaherty, E.G. (2012). Adverse experiences and suicidal ideation in adolescence: Exploring the link using the LONGSCAN samples. Psychology of Violence, 2(2), 211-225. doi: 10.1037/a0027107.

    Turner H, Finkelhor D (2020). Strengthening the predictive power of screening for adverse childhood experiences (ACEs) in younger and older children. Child Abuse and Neglect 107: 104522/

    Wood S, Ford K et al (2020). ACEs in child refugee and asylum -seeking populations 2020. Public Health Wales.

    van Ijzendoorn MH, Bakermans-Kraneburg MJ, Duschinsky R, et al (2020b) Institutionalisation and deinstitutionalization of children 1: a systematic and integrative review of evidence regarding effects on development. Lancet Psychiatry, 7: 703–20.

    Vizard E (2013) Practitioner Review: the victims and juvenile perpetrators of child sexual abuse – assessment and intervention. Journal of Child Psychology and Psychiatry, 54: 503–15.

  • Twenty years of ACEs research – what have we learned?

    1. Lifespan outcomes of Adverse Childhood Experiences and costs to the community

    Timeline of ACEs publications

    Recent papers in the January 2021 edition of the International Journal of Child Abuse and Neglect (CAN) underline the exponential growth in research in the field of ACEs in the last 20 years.

    What is unique about the last 20 years research on ACEs, and how does it differentiate from the general field of child maltreatment and child protection, and what is its relevance to child and adolescent mental health?

    2. Outcomes associated with ACEs

    ACEs are associated with a range of poor health outcomes. For example, a meta-analysis of studies by Karen Hughes and colleagues in the Lancet Public Health (2017) of 253,719 individuals found that 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.

    The associations between ACEs and mental health outcomes have been observed for ACEs examined both prospectively and retrospectively in a study at University College (Gondek, Patalay and Lacey, 2021), This was based on the Longitudinal 1958 National Child Development Study (NCDS).

    Mental health-related outcomes were assessed spanning age 16-55 years. Utilisation of mental health services, taking psychotropic medications, psychological distress, life satisfaction, quality of life, and self-reported general health were measured.

    • There was a robust dose-response association prospectively and retrospectively between reported ACEs and all mental health-related outcomes, regardless of whether ACEs were reported prospectively or retrospectively.

    3. Costs associated with ACEs

    A preliminary study of the economic costs of child maltreatment in the UK estimated that the discounted lifetime costs of non-fatal maltreatment were £89,390 per victim. Lifetime costs per death from child maltreatment were over 10 times higher, at £940,758. Bellis and colleagues (Lancet Public Health, 2019) 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).

    A later study published in Lancet Public Health (Hughes et al., 2021) estimated the annual health costs linked to ACEs in 28 European countries, and found that the total ACE-attributable costs exceeded 1% of national gross domestic product (GDP) in all countries, ranging from 1·1% (Sweden and Turkey) to 6·0% (Ukraine).

    These estimates were based on the associations between ACEs and health outcomes and therefore may not reflect direct costs caused by ACEs, which are nonetheless likely to be high. This research is allied to the direct costs associated with child maltreatment in the US, e.g. Fang (2012). The costs were attributed to the failures of education, mental and physical health, aggression, crime and violence associated with being subject to abuse and neglect – core adversities of childhood. The estimate was $200,000 for each maltreated individual.

    4. Factors which protect against the impact of ACEs

    Researchers have identified protective factors which could mitigate against poor health outcomes associated with high levels of ACEs.  The Bellis Team (Bellis, 2018) described the protective value of community assets includednetworking 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.

    Fritz and colleagues (2018) conducted a systematic review of resilience factors which moderated or mediated the relationship between childhood adversity and mental health in young people. They identified studies on individuals, the family context, and the community. Individual level protective factors which fostered resilience  included mental flexibility as opposed to rigidity, a capacity to tolerate stress, high self-esteem, a secure attachment, and not ruminating on stressful events. Family factors included living in a family with a high level of togetherness, and parents who were involved with their children, and living in communities where a high level of social support was available.

    Multiple resilience factors  supported the development of resilience more effectively than single factors. It was concluded that resilience factors should not be studied in isolation.  Interrelations between resilience factors needed to  be taken into account when predicting psychopathology after childhood adversity. Resilience factors function as a ‘complex interrelated system’.

    Some individuals may be genetically more or less vulnerable to stressful environmental influence and show resilience in the face of highly stressful events. This research has prompted considerable interest in ‘Protective Experiences’ (PACES) as a parallel to Adverse Experiences.

    5. Strengths and limitations of the ACEs score

    An ACEs profile is a cumulative risk score – reflecting  challenges across multiple domains (Dube, 2021), for example, in the cycle of ACEs influencing adult mental health and functioning, influencing parenting capacities, and on the development of children and young people.

    The ACEs score as a cumulative risk index has been used extensively in research studies. Lacey and Minnis (2019) in their review of 20 years research pointed out the strengths of ACEs score.  It was simple to understand and carry out, and more likely to find strong, statistically significant associations with outcome, and acknowledges that adversities tend to co-occur. This observation also applies to child maltreatment research, where it has been established that forms of maltreatment co-occur, and are cumulatively associated with mental health problems (Cecil et al., 2017).

    However, a limitation of the ACE score is that it 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). The score in the original research was reliant on retrospective reports likely to be biased or unreliable, and many studies focus on adult outcomes rather than child outcomes.  The associations between ACEs and subsequent health were correlational. Direct research is now being carried out on the adversity children experience and has begun to explore whether these associations were causal, and the pathways to poor health outcomes through prospective, longitudinal research.

    Lacey and Minnis (2019) stated:

    The challenge now is to find more nuanced ways of measuring and conceptualising ACEs that are still easily usable so that detailed models of development can better inform practice and policy.”

    “There is a need to carry out methodologically rigorous studies to build the evidence base of trauma-informed care as a framework and complement to trauma-specific services (p. 28).”

    They advocated a variety of different approaches, e.g. studies of specific adversities – physical abuse, neglect, or sexual abuse to elucidate the mechanisms, and compare different adversities. Other approaches e.g. research on theoretically driven themes, threat, or deprivation, or person centred, latent class analysis.

    A longitudinal study from University College (Bevilacqua et al., 2021) ‘explored the association between different ways of operationalising ACEs and later trajectories of internalizing, externalizing, and prosocial behavior from age 3–14’.

    Three approaches to operationalising ACEs were used – ACE scores, individual ACEs, and ACEs clustering using latent class analysis. It was established in line with the general finding that a higher number of ACEs predicted worse mental health and prosocial outcomes in childhood and adolescence. In most cases these differences were evident by age 3 and persisted through to adolescence.

    Exploring the impact of individual ACEs physical punishment and harsh parenting was more strongly related to externalizing behaviours, as noted in other research; parental discord and parental depression was more related to internalizing problems. In this study clustering of ACEs did not predict outcomes.

    Henry et al., (2021) compared different approaches to understanding the way ACEs influence development. This included a study of Independent Risks, e.g. particular forms of adversity, the Dimensional Model of Adversity and Psychopathology (DMAP) which gathers adversities as forms of Threat and Deprivation, and the Cumulative Risk Approach.  

    The study demonstrated the way different models helped to understand the association of ACEs with internalising and externalising symptoms in children and young people – an important finding for the Child Mental Health field.

    6. The ACEs score does not predict poor health outcomes at the individual level

    An important issue is to determine whether the ACEs score being utilised in some services, and as a screening tool, can predict poor health outcomes at the individual level.

    Baldwin and colleagues (2021) studied 2 birth cohorts: the Environmental Risk (E-Risk) Longitudinal Twin Study, including 2232 participants studied to aged 18 years, and the Dunedin Multidisciplinary Health and Development Study, including 1037 participants studied to age 45 years. ACEs were measured through repeated interviews and observations. ACEs were also measured retrospectively in the Dunedin study at 38 years. They reported that in line with other studies, ACE scores forecast mean group differences in health but showed poor accuracy in predicting an individual’s risk of later health problems.

    They concluded:

    Targeting interventions based on ACE screening is likely to be ineffective in preventing poor health outcomes”. (E6)

    Another study led by Meehan (2021) used data from the seminal ACE study (first used by Felitti et al., 1998) and found that in this ACE scores did not accurately identify individuals at high risk of health problems.

    This research confirms the harmful association of ACEs with health outcomes, but demonstrates that the ACEs score does not accurately predict such outcomes at the individual level.

    There is a tension between the recommendation to ascertain an ACEs score as part of an assessment of a child or young person referred to a service as a result of concerns – e.g. mental health, safeguarding, or offending services, and as a routine procedure in community services.

    Gentry and Paterson (2021) carried out a rapid evidence summary of whether screening or routine enquiry for adverse childhood experiences (ACEs) meet the criteria for a screening programme.

    Routine enquiry’: is defined where professionals ‘proactively and sensitively enquire about past childhood experiences with all service users and tailor support accordingly’

    ‘Screening: ‘the process of identifying healthy people who may have an increased chance of a disease or condition. The screening provider then offers information, further tests and treatment. This is to reduce associated problems or complications.’

    They matched the value of ACEs screening against established criteria for screening approaches:

    • The importance of the health problem being screened for – good evidence ACEs and health outcomes
    • Whether cost effective primary prevention had been implemented – available but not implemented
    • Whether there is a safe, precise, validated, acceptable screening test available – no consensus, suitable tool, setting, timing or frequency
    • Whether there is an agreed pathway for further investigation – safeguarding for children, limited evidence for adults
    • An effective intervention if given early – some evidence e.g. safeguarding, trauma-informed care
    • RCT evidence for the screening programme reducing morbidity and mortality – none identified
    • Whether the programme is acceptable – generally acceptable.

    They concluded.

     ‘Routine enquiry among adults (REACH) was assessed as feasible and acceptable to service users and professionals and resulted in the delivery of potentially effective interventions…… but there was doubt whether screening or routine enquiry could improve morbidity, mortality, health and well-being (p. 7).’

    7.  Research on risk calculators to identify which children exposed to ACEs will develop poor health outcomes

    Research which has been conducted balancing risk and protective factors to develop a risk calculator which identify which children exposed to ACEs will develop poor health outcomes. This was studied in a series of papers based on the longitudinal study of Twins in the Environmental Risk (E) study. Participants were 2232 twin children born in England and Wales in 1994–1995.  Lewis et al. (2019) explored the epidemiology of trauma and post-traumatic stress. Meehan et al. (2020) studied a sub-set exposed to any type of victimisation, and Lewis et al. (2021) the impact of complex trauma.

    In the subset of the E-Risk Study sample exposed to any type of victimization during childhood was studied. Victimisation included the following:

    • Exposure to victimization was assessed at 5, 7, 10, and 12 years of age
    • Cumulative information was gathered about exposure to domestic violence; frequent bullying by peers; physical abuse sexual abuse; emotional abuse and neglect; and physical neglect – all significant forms of adversity
    • Non-complex traumas were defined as a one-off assault, an accident and learning about the sudden death of a parent.

    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.

    A psychiatric assessment was conducted when the young people were aged 18, providing detailed understanding about the associations of the associations of risk and resilience factors and mental health in early adult life, with implications for the longer term.

    Psychiatric Assessment aged 18

    Graph of age 18

    The figure demonstrates that exposure to any trauma during childhood results in a spectrum of mental health responses measured at aged 18:  Post-traumatic responses, through Depression, Anxiety, Conduct disorder, Alcohol and Cannabis dependence, Psychotic symptoms, Self-harm and Suicide attempts.

    Complex trauma exposure included multiple events, interpersonal assaults or threats in childhood or adolescence, repeated child abuse, severe bullying, witnessing neighbourhood violence resulted in more extensive mental health responses.

    The studies demonstrated that when the risk and resilience factors are taken into account the more risk factors and the less resilience factors the more likely the association with any Psychiatric Disorder, Internalising or Externalising disorders.

    There was a risk of later complex trauma and more severe psychopathology, and cognitive deficits, when there was evidence of significant early vulnerabilities internalising and externalising symptoms at age 5 years, and family members with a history of mental illness.

    A further analysis of the study (Lathem et al., 2019) demonstrated that a different set of factors were associated with risk for psychosocial disadvantage or economic disadvantage. Psychosocial disadvantage was associated with individual, family and community factors, economic disadvantage with individual and family factors. The value of being able to predict which child or young person is at risk of disadvantage is an important step to prevention. The risk calculator that was developed could be used as a reliable screening tool, with an individualised score which guides intervention.

    Conclusions

    This work represents an important development in the field because it demonstrates and confirms the complexity of mental health responses to exposure to trauma associated with multiple adversities. The research also established how few of the young people in the study had received treatment for traumatic responses. Considering a range of individual, family and community risk, vulnerability and resilience predictive analytic factors could better predict mental health outcomes for the individual, and guide intervention. Balancing risk factors represented in the ACEs score with resilience factors could guide the practitioner’s assessment and intervention.

    8. Adverse Childhood Experiences are associated with neurobiological and inflammatory responses

    The traumatic impact of various forms of maltreatment and neurobiological functioning – particularly those involving threat – physical abuse, emotional abuse and sexual abuse has been well established (Teicher et al., 2016). The association between Childhood Adversity and Abuse on later health has evoked considerable research.

    A review summarising the impact of early adversity on children’s development noted that chronic stress can be toxic to the child’s development and significant early adversity can lead to lifelong problems (National Scientific Council on the Developing Child, 2008/2012). For example, when maltreatment-induced chronic elevation of cortisol occurs in the context of ‘toxic stress’, damaging effects in the brain can include deficits in memory formation and recall and impaired cognitive control over thought, emotion and behaviours, resulting in poorer later performance in school, the workplace and relationships (Vizard et al.. 2021, p. 5).

    McCrory and Viding (2017) observe that neuro-biological and neuro-cognitive systems adapt to early abusive and neglectful experiences. The classical post-traumatic responses of heightened response to threat, avoidance and turning away from relationships, restricted memories provide short-term functional advantages to atypical environments, but compromise the capacity of the individual to negotiate more normative contexts or adapt to future stressor events. Latent vulnerabilities predict future psychiatric risk, before disorders emerge. Brain differences are markers of latent vulnerability at the neural level and impacts on establishing relationships in the family, school and community.

    The Dunedin Multi-Disciplinary Health and Development study (Danese, 2007) investigated significant biomarkers of inflammation in adulthood, investigating links with later Inflammatory Disease. They found a significant association between childhood maltreatment in the first decade of life and elevated adult inflammatory markers such as C-Reactive Protein (CRP). It was already known that adult health outcomes linked to these inflammatory biomarkers included cardiovascular disease, diabetes and chronic lung disease. The association between childhood adversity and inflammation has since been reported in meta-analytic research (Baumeister et al., 2015) although stronger associations are found for inflammation in adulthood relative to childhood (Kuhlman et al., 2020).

    Cumulative exposure to adversity may be associated with ‘allostatic overload’, beyond the usual bodily ‘wear and tear‘, and may cause the normal neurobiological responses to become pathological rather than protective, and to attack the child’s body with raised inflammatory markers. (Danese and McEwan, 2012). A link is examined between stress, cardiac responses, inflammatory responses, accelerated aging of chromosomes – telomere length and psychopathology. A variety of early adverse events – divorce, separation, physical abuse, and multiple adversity – were associated with later inflammatory responses (Nelson et al., 2021).

    Allostasis

    Lacey and colleagues (2020) based on the Longitudinal 1958 British birth cohort were able to use a variety of different models to explore the association of Adverse Childhood Experiences reported prospectively and retrospectively with inflammatory processes. Single adversities, cumulative risk and Latent Class Approaches were studied for possible associations with chronic inflammatory processes. The authors concluded that looking at combinations of ACEs could be a helpful alternative way of operationalizing ACEs.

    Current research on ACEs is beginning to move from the original focus on the association with harmful outcomes with a cumulative impact of ACEs to a more nuanced understanding of the processes which underpin the longer-term impact of adversity in childhood.

    Longitudinal studies looking at the later adverse impact of ACEs on children’s mental health and brain functioning suggest that early damage to a child’s developing brain is not necessarily irreversible. The brain retains plasticity throughout the lifetime and if the child has acquired sufficient life-course resilience from a relationship with an ‘always available adult’, recovery from early ACEs may be possible, at least in part (Bellis, 2017).

    References

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    Baumeister, D., Akhtar, R., Pariante C.M., Mondelli, V. (2016) Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α. Mol Psychiatry, 21, 642 – 649

    Bellis MA, Hardcastle K, Ford K, et al (2017) Does continuous trusted adult support in childhood impart life-course resilience against adverse child- hood experiences – a retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry, 17, 1, 110.

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    Cecil, C.A.M., Viding, E., Fearon, P., Glaser, D., & McCrory, E.J. (2017). Disentangling the mental health of childhood abuse and neglect. Child Abuse and Neglect, 63, 106-119.

    Conti G, Morris S, Melnychuk M, et al (2017) The Economic Costs of Child Maltreatment in the UK: A Preliminary Study. NSPCC.

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    Available from:  https://www.cambridge.org/core/journals/bjpsych-advances/article/impact-of-child-maltreatment-on-the-mental-and-physical-health-of-child-victims-a-review-of-the-evidence/D5A662192092FADD5E9F594B65C083FA/share/bf4f35a8cd7c6f7fbd92ed4bf8c44e8c13b88247