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A more compassionate Scotland: a societal response to childhood adversity

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A more compassionate Scotland: a societal response to childhood adversity

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Feeling loved, being nurtured and having a safe environment in which to learn, develop and explore the world gives us the best start in life. We often have compassion and understanding for babies and young children, but it can be more challenging to keep in mind how adverse circumstances in childhood can shape our development into adulthood*. The growing interest in childhood adversity, across civic society in the UK and elsewhere, gives us increased impetus to organise a fairer society. We have the means to improve the lives of people today and to influence the world in which children will grow up.

It isn't just about the early years. Children grow up. The research reminds us that historical experiences, good and bad, affect our health and wellbeing as adults. They impact on opportunities for education and work, and our ability to trust and build healthy relationships. Quite simply, if you've learned not to trust, then this can get in the way with how you interact with people who try to help you, such as teachers or housing officers. Without interaction there is a tendency to be excluded rather than understood.

Widespread discussion stimulated by the ACEs research is welcome. In fact, I'd argue it's necessary. It strengthens the case for preventing adversity in childhood within the wider context of the social determinants of health.

Through our Scottish ACEs Hub, a small group of people who work in health, education, justice, academia and the voluntary sector, we are leading the way on ACEs and doing what we can to ensure our national policies and services are responsive. As part of this, we have produced a short paper, Adverse Childhood Experiences in Context. The paper recognises the cautions against taking a narrow interpretation of ACE studies and sets out how various sectors can use the principles behind ACEs to inform their work.

Preventing adversity in childhood requires actions at a number of levels. Legislation and policy is important because it can help create a more equal society and the conditions which support families to give children the best start in life. Scotland is making progress in this area. For example through the Proposed Children (Equal Protection Assault) Bill, a commitment to incorporate the UNCRC into domestic legislation, and the Child Poverty (Scotland) Act. Policies such as 'Equally Safe - Scotland's strategy to prevent and eradicate violence against women and girls', seeks to address the inequalities in society which affect the world in which children live and grow up in.

And, there's the National Trauma Training Framework and Training Plan. This aims to create a workforce that is trauma informed. An understanding about what might have happened in a person's life and how that might have affected them should 'create compassion in a psychologically informed society' as our ScotPHN report Polishing the Diamonds - Addressing Adverse Childhood Experiences in Scotland proposed in 2016.

What has struck me the most through my work on childhood adversity is the importance of a whole society response. It is not simply the job of the health, education, justice or other sector in isolation. All sectors, as well as communities and families, need to take account of, learn from and prevent ACEs. It is a big ask, including action to undo social inequalities. But knowledge about what builds health and wellbeing in the population and what can disrupt it is also key, and the good news is we're building more of this into our practice and research, every day.

Some might think it glib to talk about compassion and relationships when structural intervention gets to the heart of the problem. But it's not an either/or approach. If we have this in mind as we work with people, their families and communities - and as we design our public services, laws and policies - then I believe we can create the sort of society where children thrive, inequalities narrow, and we all live longer, healthier lives.

* The field of research on adverse childhood experiences (ACEs) has repeatedly shown the associations between adverse and traumatic experiences in childhood, and a range of health and social impacts in adulthood.

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A more compassionate Scotland: a societal response to childhood adversity

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In the absence of healthy relationships there is a tendency to be excluded instead of understood. We blog about the need to improve people's lives today - as well as influence the world that children will grow up in - as part of a societal response to childhood adversity.

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Full article only available with purchase of CiS magazine

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Kicking off the special early years edition of Children in Scotland Magazine, Aberlour CEO SallyAnn Kelly and developmental psychologist Suzanne Zeedyk discuss whether the Adverse Childhood Experiences approach is too narrow - or offers the potential for real societal change
SallyAnn: I believe we need societal level change not only to prevent ACEs, but to better aid recovery and healing for those who do experience childhood adversity. I am really encouraged that there has been a commitment from the Scottish Government to aim to address childhood adversity in its widest sense and that included within that frame of reference is a clear statement regarding the potential impact of structural inequality.

But there must be greater recognition that tackling childhood adversity cannot be achieved by focusing only on adversity happening within and from family interactions (as the ACE studies do) and a clear understanding that we need to focus on those structural inequalities such as poverty and discrimination.

Right now, 240,000 children in Scotland live in poverty. There is broad agreement that lifting children out of poverty acts as an effective buffer to the risk of toxic stress on families, as it serves to improve relational heath between families and their children and reduces exposure to trauma.

Yet, we still don't appear able to grasp that decisive action in this area is one of the single most effective preventative measures that we have at our disposal. It concerns me that much of the discussion around ACEs misses out these important issues.

The ACEs approach categorises childhood adversity into types of abuse, neglect and household dysfunction, and then allocates an individual ACEs score. However, these categories do not cover every potentially traumatic event a child could experience. In the original ACEs study conducted in the United States during the 1990s - on which the ACEs approach is based - the participants were overwhelmingly white and college educated.

There was no consideration in the study of the impact of structural inequalities or the discrimination faced by women and refugee, BME and LGBT communities. I, in common with many others, believe this presents a significant gap in the reach of the ACEs approach.

It does not, though, mean that we shouldn't use the research, but that we should display caution. If we are to address all forms of childhood adversity then we need to make sure we are inclusive of all communities in how we do that.

Suzanne: I agree. Many of the pressures on families that exacerbate and cause trauma derive from societal causes: poverty; insufficient family support; pressures that prevent work-life balance; poor housing; violence; cultural ideas about gender, race, class and children's rights. We need society-level changes that place relationships at the centre of absolutely everything we do.

The film Resilience has had a massive impact on our thinking in Scotland. As one of the people who brought that film to Scotland in 2017, alongside Tina Hendry, that impact has been a surprise to me. An ACEs framework was not new to Scotland. Many people had been discussing it since Chief Medical Officer Harry Burns and the Violence Reduction Unit first brought it to our attention in 2005.

However, once the film was available, interest in it and in ACEs exploded. Two years on, tens of thousands of Scots have seen the film. I tell this story because I now wonder if that film has been almost too impactful. It is only one hour long and can only tell a part of the ACEs story, but many people remain unaware, as yet, of that wider story. We can only get to that deeper level of awareness by having more conversations. The film Resilience is a conversation-starter, nothing more. We are now each responsible for getting curious about what else there is to learn about ACEs.

It is true, as SallyAnn says, that the original ACEs Study in 1998 focused on family factors, and the original triangular model that is now familiar to many people seems to emphasise those. But 20 years of scientific research have been undertaken since then, yielding hundreds of additional papers.

Many have now emphasised societal factors, like poverty, violence, inequality, racism, living in a war zone. Others have highlighted family and personal factors, such as bereavement, bullying, periods of hospitalisation, household moves, and care experience. New forms of the ACEs survey have been developed, some of which contain more than the common 10 items and some that contain fewer.

So, it isn't accurate to say that ACEs studies haven't focused on contextual factors. Indeed, one of the organisations leading on public education, ACEs Too High, describes ACEs as "falling into three large categories": 'adverse childhood experiences', 'adverse community experiences' and 'adverse climate experiences'.

SallyAnn sees the debate as growing from the failure of ACEs studies themselves to sufficiently consider these contextual factors. I think the problem lies not with the ACEs research, but with the public's insufficient awareness of the wider body of scientific work. A good place to begin is the 2018 NHS Highland Report entitled ACES, Resilience and Trauma-Informed Care.

We have a challenge on our hands, and it is one we must find a way to tackle. As a country, we are trying to find ways to act on an area of science that is still in development. This is not unlike the challenge that society faced as evidence emerged of the impact of cigarette smoking. Should we have waited as long as we did to develop anti-smoking policies?

The question we are facing as a society right now is: how long should we wait to develop new policies on the basis of evidence we currently have about toxic stress? We have decided we need to act now, on the basis of what we do know. I think that is the right decision, given that people's lives are at stake. But it means that we will need plenty of curiosity and conversation.

SallyAnn: For me, the ACEs approach is useful only at a whole-population level and should not be used as a mechanism for either screening or routine enquiry of children. I believe that everyone who experiences adversity can flourish with the right support, that relationships are key and that it is possible for Scotland to become a country that recognises and responds to adversity in all its forms.

For that to happen we need to see real system change and a fundamental shift to becoming focused on people and relationships across all of our systems, structures and organisations. Few people escape some form of adversity completely, and I believe we must ensure that we have the capacity and compassion as a society to support people who have experienced adversity in their lives.

This means understanding and recognising all forms of adversity that affect children, as well as the potential to experience trauma as a result of that adversity, and how we help people to heal. This will require greater collaboration across all sectors, as well as more resource and investment, if we are to become a truly trauma-responsive society.

We know that in countries where there are good relationships within society, where the value of human beings is separate to their capacity to create wealth and where human relationships are valued, there is the highest quality of life and lowest levels of adversity. This is the kind of Scotland we shall all aspire to create.
To read the rest of the conversation between SallyAnn Kelly and Suzanne Zeedyk, and the wide range of content in our early years issue, to buy a print copy or subscribe to the magazine for a year by contacting clogan@childreninscotland.org.uk

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By bringing together a network of people working with and for children, alongside children and young people themselves, we offer a broad, balanced and independent voice. We create solutions, provide support and develop positive change across all areas affecting children in Scotland.

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Adverse childhood experiences in context

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Adverse childhood experiences in context

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Briefing paper

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Improving Health - Public Health Scotland

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The National Health Board working to reduce health inequalities and improve population health in Scotland. Find public health research, evidence, evaluations and resources. For practitioners and policymakers, Community Planning and Health and Social Care Partnerships, and other public service staff.

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The circumstances in which people live impact directly on their physical and mental health. Their importance as a determinant of health is widely recognised. This part of the website covers some of the more influential aspects of life circumstances, with a range of often overlapping topics. These are:

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Essential Maintenance

The Place Standard tool is currently undergoing some essential maintenance and will be offline for a short while. Apologies for any inconvenience that this might cause and we hope to be up and running again very soon but if you have any questions in the meantime then please get in touch at placestandard@gov.scot.

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Essential Maintenance The Place Standard tool is currently undergoing some essential maintenance and will be offline for a short while. Apologies for any inconvenience that this might cause and we hope to be up and running again very soon but if you have any questions in the meantime then please get in touch at placestandard@gov.scot.

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Interactive resource to learn about the concept of ‘resilience’ and the value of ‘protective factors’ in planning to support vulnerable children.

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Understanding resilience - the concept of 'resilience' and the value of 'protective factors' in planning to support vulnerable children.

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Learn about the concept of 'resilience' and the value of 'protective factors' in planning to support vulnerable children.

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Annual Report of the Director of Public Health 2018: Executive Summary Report

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Annual Report of the Director of Public Health 2018: Executive Summary Report

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NHS Highland - interactive report

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Why ACEs are key to behaviour management

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Why ACEs are key to behaviour management

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In 1998, a group of medical researchers carried out a large-scale analysis of the effects of a range of childhood stressors upon both mental and physical health. The number of effects surprised them, so much so they grouped the most significant impacts (these principally related to violence, abuse or addiction within the home) and called them "adverse childhood experiences".

This was the first ACE.

The second came some years later. Researchers moved from events inside the home to broader environmental circumstances; for example, poverty, poor housing and violent neighbourhoods (Ellis and Dietz, 2017). This ACE stands for Adverse Community Experiences.

Both ACEs are clearly important considerations for teachers.

Adverse childhood experiences

In early life, children create what John Bowlby (1988) referred to as an "internal working model", drawing from the behaviour of significant adults towards them. They learn whether to expect adults to be (for example) calm, affectionate and helpful, or angry and distracted.

Quick read: How teachers can influence behaviour

Quick listen: what you need to know about the impact of trauma

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From this information, they subsequently evaluate their own worth; whether they are worthy of adults' attention and affection or not.

If this model is constructed in an atmosphere where the family lives in a situation where the two ACES are more likely to occur - for example desperate poverty, poorly clothed, under threat of eviction, battling bailiffs and relying on food banks to get through the week - it is almost impossible to prevent the resultant stress and despair impacting to some extent upon children's socio-emotional development.

Long-term impact

Children whose first experiences of the world have been steeped in toxic stress typically have higher resting levels of cortisol and take longer to return to baseline after stressful episodes.

A simplified comparison can be made between a continually stressed brain and a computer constantly running a program that takes up a significant amount of its processing capacity. Implications for such a child include the following:

Fight or flight response always on stand-by

Quick to anger, to sadness and "learned helplessness"

Short attention span

Problems concentrating at school

View of the world as a dangerous place

Mistrustful of adults and other children

Feeling of inadequacy/ lacking confidence

Lack of self-belief/ lack of self-motivation

May be over-dependent upon opinion/ support of others (preoccupied)

May reject support from others (dismissive)

From this premise, we can more easily reflect upon how non-familial adults (ie teachers) modelling anger and punitive behaviour may be received by children whose stress-coping systems already operate at too high a setting.

School-led solutions

While it may certainly be the case that children "kicking off" need somewhere away from the classroom to cool down alongside focused care and support from pastoral staff, imposed isolation and "shouting at" strategies clearly stand to make all these problems worse by raising already toxic stress levels.

Instead of taking the attitude there is something "wrong" with a child with consistent behaviour problems, professional adults should be available to thoroughly explore the question: "What happened to you?" (Jarvis 2018).

If we reconstruct chronic "problem behaviour" as "distressed behaviour" in this way, we can reframe the problem and consider ways to address it far more positively.

Shonkoff et al (2015) found that just one supportive adult-child relationship could blunt the impact of ACEs, concluding "resilience requires relationships" (p7).

Making a change

Does this happen enough in schools? In some, it is standard practice. In others, it is far too overlooked.

From this perspective, some of the recommendations of the recent Timpson report appear to be quite promising, particularly the requirement for schools to retain their responsibility for excluded pupils.

This could prevent children who have already been damaged by toxic stress experiencing yet more adult anger and rejection, and offer potential for pastoral staff to work closely with individual children, becoming what Shonkoff referred to as the "trusted available adult".

This would not be a cheap option. But besides creating an effective, humane response to childhood trauma, it would eventually increase the numbers of functional adults in society who are adequately emotionally prepared for both parenting and employment. And it is also worth considering whether, in the final analysis, addressing these issues effectively in childhood would be a lot less expensive than providing mental health support, addiction treatment and criminal justice responses for chronically emotionally damaged adults, generation following generation.
Dr Pam Jarvis is a reader in childhood, youth and education at Leeds Trinity University
Further reading:

Allen-Kinross, P (2019) Timpson exclusions review: DfE pledges alternative provision shake-up, Schools Week. Available here.

Child Poverty Action Group (2019) Child Poverty Facts and Figures. Available here.

Cocozza, P (2017) How childhood stress can knock 20 Years off your life, The Guardian

Ellis, W, Dietz, W (2017) "A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model", Academic Pediatrics, 17 (7S) http://dx.doi.org/10.1016/j.acap.2016.12.011. Available here.

Felitti, V, Anda, R, Nordenberg, D, Williamson, D et al (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

Jarvis, P (2018) "ACEs too high? Educating Yorkshire in Adverse Childhood Experiences Awareness", Leeds Trinity University Blog. Available here.

Jensen, E (2009) Teaching with Poverty in Mind. Available here

Shonkoff, J, Levitt, P, Bunge, S, Cameron, J et al, "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 here

Couper, S, Mackie, P (2016) "Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland", Scot PHN report. Available here.

Dube, S, Felitti, V, Dong, M, Giles, W et al (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

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Why ACEs are key to behaviour management

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In 1998, a group of medical researchers carried out a large-scale analysis of the effects of a range of childhood stressors upon both mental and physical health. The number of effects surprised them, so much so they grouped the most significant impacts (these principally related to violence, abuse or addiction within the home) and called them "adverse childhood experiences".

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The BCR Pair of ACEs tree image grew out of the need to illustrate the relationship between adversity within a family and adversity within a community

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This article originally made reference to Sir Martin Narey's 2014 report of his review of children's social work education, saying that it demanded that "social work education dispense with its analysis of poverty, social exclusion and the political nature of the 'personal' as a foundation on which to intervene in people's lives".

The Narey report did not make such a demand. It did criticise the teaching of anti-oppressive practice in social work education but said: "I am not suggesting that the role of disadvantage and inequality in exacerbating poor parenting and child neglect or abuse should not be discussed at university. But it is vital that social work education for those working with children is not dominated by theories of non-oppressive practice, empowerment and partnership."

As well as carrying out this review, Sir Martin was chief executive of Barnardo's from 2005-11 and was for three years the chair of the End Child Poverty Coalition. We apologise for this error.

by Diane Galpin, Annastasia Maksymluk and Andy Whiteford

Last year we undertook research on the place and meaning of resilience in social work practice. This stemmed from anecdotal information from practitioners, who suggested resilience is a term used to divert attention away from failures within the system caused by significant structural and organisational issues.

Our research is timely given recent reports in respect of retention rates, which might suggest to some that practitioners are not demonstrating 'enough' resilience once in practice.

These results may also reaffirm the importance of resilience as both a professional capability and a regulatory requirement under both the current HCPC framework and the incoming Social Work England.

But is anyone asking why social workers are 'failing' to be resilient?

Our initial findings provide some insight into the nebulous nature of resilience, which currently lacks a clear positive definition. They also highlight how practitioners are interpreting it to fill the void in meaning and application that exists within regulatory and organisational contexts. They suggest 'resilience' is being used in professional settings as a metaphor to blame individuals for not coping with ever-increasing workloads, ever-diminishing resources and significant political, structural and organisational failings.

Limited knowledge

We used a short online questionnaire to gather professional views and opinions. Participants were self-selecting in terms of age, gender, level of experience, ethnicity and geographical location.

A total of 506 participants responded to the survey, 97% of whom were HCPC-registered. They were aged between 21 and 75, with about one quarter each in the 25-34 and 35-44 age groups and one third in the 45-54 bracket. In keeping with the profession as a whole, 88% of participants identified as female and 12% as male.

Six in 10 respondents had between zero and 10 years' post-qualifying experience. Almost two-thirds (64%) qualified via traditional bachelor's and master's degrees, with a further 8% having arrived via one of the new fast-track routes such as Step Up, Frontline or Think Ahead.

When asked about how their employer defines resilience, participants appeared to have limited knowledge. Fifty-two per cent of responses were based on individual experience in practice rather than organisational policies, with responses such as "not going off sick" or "never complaining about increased workloads".

The remainder (48%) gave responses such as "unclear", "unknown", "it doesn't" or "I don't know". This is representative of the general tone of responses to this question, though there were a few who provided a more positive view, which related to their manager providing support.

Individual responses to adversity

Participants were also asked what they understood by the term 'resilience'. Our analysis overwhelmingly revealed an embedded belief that resilience relates to responding to adversity, a basic dictionary definition of which alludes to a difficult or unpleasant situation.

Comments from participants repeatedly refer to attributes that an individual innately has or must develop; for example the ability to recover from setbacks, bounce back or withstand, or to develop coping mechanisms. A significant theme in the responses indicates a belief that whatever the difficult or unpleasant situation is, it should be borne on an individualised basis.

Participants also referred to the 'emotional' nature of their work: managing their own emotions and/or managing the emotions of service users. Many felt they need to compartmentalise these emotions.

This was indicated with comments such as "being able to emotionally support yourself to have a shield against stresses", "using emotional intelligence to regulate yourself and protect yourself from harm", and "working hard to not become emotionally involved".

When practitioners were asked to identify areas in which the concept of resilience was being applied within their organisation, their responses continued to endorse the idea that resilience is being applied to individual wellbeing and the capability to meet organisational expectations, with failure to do attributed to individual failings.

A noticeable proportion of respondents could not specifically identify where and/or to what extent resilience is linked to their practice, while others signalled it was associated with all aspects of their practice experience.

Interestingly this question also reveals how and to what extent the concept is being applied to direct work with children and family safeguarding, to a lesser extent in fostering and adoption work and with some mention of adult work in relation to mental health and safeguarding. Practice in this regard appears to be organised around building and strengthening the 'resilience' of individuals, their networks and relationships.

Lack of clarity

Our aim with this project was to give a voice to social workers to challenge and inform current practice. We wanted to provide social workers with an opportunity to tell us how it really is, to go beyond the rhetoric of resilience to establish the reality in contemporary practice.

Respondents clearly understand 'resilience' is a regulatory requirement. But it is also apparent there is a lack of structural or organisational clarity in defining what this actually means, and suggesting how this might be met, or achieved, beyond individual social workers managing themselves. This has created a void that practitioners are filling based on their experience in practice.

The discourse in relation to resilience and social work practice consistently refers to the idea of an innate strength or capacity available to humans enabling recovery from trauma and stress, and the development of an approach to practice that seeks to identify and strengthen individual coping strategies in isolation from the political and organisational contexts of practice.

These interconnections have become acknowledged as a central organising feature of an individualised depoliticised 'resilience framework', which then guides social workers in applying resilience in their practice with those who require services.

But by not accounting for factors arising from wider political, structural and organisational frameworks, which shape practice, the apparent one-dimensional individualised experience of 'resilience' has the potential to construct oppressive practices, which veils wider issues.

The insights provided by practitioners in this research suggests there is a need within both social work practice and education to re-prioritise a critical and informed response to resilience as part of relocating professional practice within a much broader context than individualised frames of reference.
Diane Galpin, Annastasia Maksymluk and Andy Whiteford are social work academics based at the University of Plymouth.

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Is anyone asking why social workers are 'failing' to be resilient?

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Correction from Community Care This article originally made reference to Sir Martin Narey's 2014 report of his review of children's social work education, saying that it demanded that "social work education dispense with its analysis of poverty, social exclusion and the political nature of the 'personal' as a foundation on which to intervene in people's [...]

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Lynne Neagle: 'Building resilience in young people is vital'

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The Welsh assembly member is calling for urgent action on child mental health

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Legislators, caregivers and the media increasingly recognize that childhood adversity poses risks to individual health and well-being. The original Adverse Childhood Experiences (ACEs) Study has helped raise public awareness about this critical public health issue. However, as the use of ACEs questionnaires for identifying potentially harmful childhood experiences has gained popularity, it is important to understand how ACEs differ from other commonly used terms, including childhood adversity, trauma, and toxic stress.

Childhood adversity is a broad term that refers to a wide range of circumstances or events that pose a serious threat to a child's physical or psychological well-being. Common examples of childhood adversity include child abuse and neglect, domestic violence, bullying, serious accidents or injuries, discrimination, extreme poverty, and community violence. Research shows that such experiences can have serious consequences, especially when they occur early in life, are chronic and/or severe, or accumulate over time.

For example, the effects of childhood adversity can become biologically embedded during sensitive periods of development and lead to lifelong physical and mental health problems. However, adversity does not predestine children to poor outcomes, and most children are able to recover when they have the right supports - particularly the consistent presence of a warm, sensitive caregiver.

Adverse childhood experiences (ACEs) - a term coined by researchers Vincent Felitti, Robert Anda, and their colleagues in their seminal study conducted from 1995 to 1997 - are a subset of childhood adversities. The researchers asked adults about childhood adversities in seven categories: physical, sexual, and emotional abuse; having a mother who was treated violently; living with someone who was mentally ill; living with someone who abused alcohol or drugs; and incarceration of a member of the household. Researchers found that the more ACEs adults reported from their childhoods, the worse their physical and mental health outcomes (e.g., heart disease, substance misuse, depression). The term ACEs has since been adopted to describe varying lists of adversities. The current ACEs study funded by the Centers for Disease Control and Prevention, for example, includes parental divorce or separation and emotional and physical neglect; other studies have added experiences of social disadvantage (e.g., economic hardship, homelessness, community violence, discrimination, historical trauma).

No ACEs lists or screening tools identify all childhood adversities, but those that do not include adversity related to social disadvantage are likely to overlook children in specific racial or ethnic groups, who are disproportionately affected. It is equally important to assess each child's well-being to inform the type(s) of services that would most benefit that child. Gaining a full picture of a child can avoid overtreatment of children who have been exposed to ACEs but are functioning well.

is one possible outcome of exposure to adversity. Trauma occurs when a person perceives an event or set of circumstances as extremely frightening, harmful, or threatening - either emotionally, physically, or both. With trauma, a child's experience of strong negative emotions (e.g., terror or helplessness) and physiological symptoms (e.g., rapid heartbeat, bedwetting, stomach aches) may develop soon afterward and continue well beyond their initial exposure. Certain types of childhood adversity are especially likely to cause trauma reactions in children, such as the sudden loss of a family member, a natural disaster, a serious car accident, or a school shooting. Other childhood adversities (e.g., parental separation or divorce) tend to be associated with more variability in children's reactions and may or may not be experienced by a child as trauma. Childhood trauma is associated with problems across multiple domains of development. However, trauma affects each child differently, depending on his or her individual, family, and environmental risk and protective factors. For example, two children who experience the same type of adversity may respond in distinct ways: One may recover quickly without significant distress, whereas another may develop posttraumatic stress disorder (PTSD) and benefit from professional help (for example, the services and supports that comprise trauma-informed care).

Toxic stress can occur when a child experiences adversity that is extreme, long-lasting, and severe (e.g., chronic neglect, domestic violence, severe economic hardship) without adequate support from a caregiving adult. Specifically, childhood adversities, including ACEs, can over-activate the child's stress response system, wearing down the body and brain over time. This overactivation is referred to as toxic stress and is the primary way in which adversity damages a child's development and well-being. The extent to which a child's stress response to adversity becomes toxic and leads to serious health and mental health problems in adulthood also depends on the child's biological makeup (e.g., genetic vulnerabilities, prior experiences that have damaged the stress response system or limited healthy gene expression) and the characteristics of the adverse events or conditions (e.g., intensity, duration, whether a caregiver caused the child harm).

The increased public understanding that childhood adversity, including ACEs, can cause trauma and toxic stress - and, in turn, have a lasting impact on children's physical and mental health - presents an important opportunity to turn this awareness into action. For example, caregivers and other practitioners can learn about and implement trauma-informed care in child and family service systems. However, we must also take caution to avoid an exclusive focus on ACEs at the expense of understanding the full range of childhood adversity and considerable variation in children's responses to it. Otherwise, we risk allowing some of the most vulnerable children who are in need of support to fall through the cracks while pathologizing and overtreating other children who do not need services.
Jessica Dym Bartlett is an expert in childhood trauma and adversity at Child Trends. Vanessa Sacks is an expert in youth development (including adverse childhood experiences) at Child Trends. This article first appeared in Child Trends and has been reprinted with permission. Child Trends is a nonpartisan, nonprofit research organization based outside of Washington, D.C.

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How Adverse Childhood Experiences Are Different Than Child Trauma

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Legislators, caregivers and the media increasingly recognize that childhood adversity poses risks to individual health and well-being. The original Adverse Childhood Experiences (ACEs) Study has helped raise public awareness about this critical public health issue.

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Practitioners across a range of disciplines who work carefully and respectfully and operate within the bounds of their professional registrations are perhaps, like me, feeling slightly ill-at-ease in the wake of the recent "ACE-aware" movement.

The ACE study was conducted some 20 years ago in the States by the Centres for Disease Control and Prevention and Kaiser Permanente (Felitti et al., 1998) and has generated many papers since.

It grew out of an attempt by researchers to try to understand why mainly white, middle-class Americans who had private health insurance were continuing to suffer ill-health despite medical advice and intervention.

Using a questionnaire asking these patients about difficult events they had experienced in childhood - Adverse Childhood Experiences (ACEs) - they found that those with a higher number of ACEs were more likely to have physical health difficulties, engage in health-related risk-taking behaviours, suffer from mental ill health and report lower wellbeing ratings. Those with the most ACEs were more likely to die some 20 years earlier than those with less childhood trauma.

These findings have then been generalised into other populations such as school-aged pupils, with reports now saying that those children with four or more ACEs are more likely than their peers to experience a range of negative outcomes both in the short and longer term.

The original ACE study was seminal for two reasons. In terms of public health, it provided "hard" data at a population level and it offered a very compelling and shorthand way of presenting the issues that practitioners in this field already knew: traumatic experiences which occur earliest in a child's life and occur repeatedly, can have a lasting impact on all areas of their development in childhood and beyond.

I say "can", however, because, as skilled practitioners well know, there is far more to childhood trauma than the event itself - or how many ACEs children and young people or, more alarmingly, professionals can "score". It is the experience, or impact of the event, that is important. Different people experience the same event in different ways depending on a whole variety of factors - age, gender, previous history of traumatic events, health factors and crucially each person's resilience. Some people are able to "bounce back from tough times" easier than others due to the individual factors mentioned above and/or the social support systems they have access to.

There is a massive difference between being "ACE-aware" and trauma-informed practice. I am not suggesting that the ACE-aware movement is wrong per se. It has increased public awareness of the potentially traumatic situations that sadly many of our children and families face today and highlighted the potentially long-lasting implications of these events for our children's development well into adulthood. However, we need to be very cautious, and no matter how well-intentioned this movement may be, we need to be extremely mindful that we are not further traumatising the very children and families this movement is claiming to be helping.

Knowing your ACE score as an adult or counting up the ACE scores of any children you know is foolhardy at best, and downright dangerous at worst. Firstly, using the ACE questionnaire - which was a retrospective, population-level questionnaire designed for white, middle-class, privately-insured adult Americans to reflect on their childhood experiences - is not valid or reliable when used with individual children or families.

Secondly, it does not cover all the major traumatic events that a child could experience; crucially, it leaves out the death of a parent.

Thirdly, it does not assess the impact of the event, only the number of experiences originally deemed traumatic by the researchers. It does not ask about social supports or other features of resilience which are key in mediating an individual's experience of a traumatic event, and crucial in determining how best to intervene to support a child and family. As Bruce Perry, the eminent child psychiatrist and senior fellow of the Child Trauma Academy in the US, says, "history of relational connectedness is a more powerful indicator of health outcomes than 'ACEs'".

Fourthly, it was not designed to ask children to report the number of traumatic events they have experienced, but instead asks adults to retrospectively reflect on their childhood experience. Practitioners working in a truly trauma-informed way, rather than just being "ACE-aware", work hard to choose developmentally appropriate measures to assess the child's experience of traumatic events - from both the child's own perspective and that of those closest to them - and triangulate that with a wider assessment of their strengths and resilience factors. This assessment information is then used to begin to formulate possible approaches for supporting the child and key adults in their lives to understand and help co-regulate the child's stress-response system to these events.

Finally, this focus on only the number of negative events a child has experienced risks leaving the child and family feeling further disempowered and potentially re-traumatised, which, as any appropriately skilled practitioner will know, is contrary to the key principle of trauma-informed practice of helping the child regain a sense of control over their world.

Counting the ACE score of attendees at a one-off training event is a gimmick, the stuff of those who lack the wisdom to know that such activities have no impact on the children and families who require our support, and may potentially re-trigger members of the audience who have themselves suffered distressing times in the past. Supporting children and families to regain some control over any traumatic events they have experienced takes a responsible, measured and empathetic response that requires knowledge and experience of how to implement and sustain improvements overtime.

There have been many "next big things" which have died as quickly as their promoters move onto the next big thing. We need to use the knowledge and experience of appropriately-skilled individuals to develop trauma-informed systems of support that range from raising awareness of some children and young people's experiences - so that they are not further stigmatised by society's perceptions of how they respond in the aftermath of trauma - through to practical, evidence-based approaches to helping children regulate and manage their stress systems in the aftermath of traumatic experiences. Again, the measured application of neuroscience approaches to helping our development of trauma-informed approaches is key, but needs to go beyond the trite application of the "biology of ACEs" in terms of merely "being kind".

Trauma is complex and the experiences some of our children and families go through is harrowing; they deserve support that is skilled, measured and does not potentially re-traumatise them by further removing their sense of control or self-worth, having reduced them to an arbitrary ACE-score. Peddling simple "one-size fits all" solutions to complex problems, whilst potentially enticing to some, is dangerous on many levels:

it diverts public, professional and political attention and resources into wasted endeavours with no long-term sustainability or measurable impact

it masks the wider debates that should be taken forward into what social-political factors are perpetuating the continuation of circumstances that make childhood trauma more likely, such as poverty. All children who are traumatised are not living in poverty, but living in poverty significantly increases the likelihood of traumatic experiences occurring

it promotes a culture of complacency where we can feel we have "helped" by attending one-off training events or donating money to buy items which we think will somehow alleviate the circumstances in which these children find themselves. In fact, we are in danger of participating in an "ACEs safari" akin to the "poverty safari" described so insightfully by Darren McGarvey in his book of the same name: a throng of "tourists" throwing open the windows of the tour bus to stare in abject horror at the trauma suffered by the masses. Tourists who then donate money to buy teddies for the poor, traumatised souls, and then rush back to their own lives feeling they have done their bit.

Our children and families deserve more than this. They deserve interventions that are both developmentally appropriate and trauma-specific. Interventions which take into account the complexity of childhood trauma and adversity, as well as the views of those who have experienced trauma in their lives. Interventions which are based on the principles of implementation science in order to effect change and sustain improvements in the longer term (see Moir 2018 regarding the importance of implementation science for educational interventions).

Educational psychologists are one such group of professionals who have the knowledge and experience to take forward interventions which take all these factors into account. Scotland's Curriculum for Excellence (CfE), the National Improvement Framework (NIF) and Getting it Right for Every Child (Girfec) are all relevant areas where educational psychologists and others are already contributing to tackling the complex issues around disadvantage. Educational psychology's involvement in curricular and professional development materials such as Education Scotland's The Compassionate and Connected Classroom and the Readiness for Learning Approach (R4L) within my own authority (see "My brain's all shaky", Tes Scotland, 7 September) are examples of the profession supporting implementation of developmentally appropriate, trauma-informed interventions.

Finally, I would encourage any individuals who share my concerns about the limits of the ACE-aware movement to speak up more and stand alongside others who are trying to move the focus beyond ACEs, towards asset-based, evidence-based and trauma-informed approaches to supporting our children and families.
Whitney Barrett is principal educational psychologist at Clackmannanshire Educational Psychology Service References:
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P. and Marks, J.S. (1998) Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults American Journal of Preventative Medicine 14 (4), p. 245-258

McGarvey, D. (2017) Poverty Safari Luath Press Ltd., Edinburgh

Moir, T. (2018) Why is implementation science important for intervention design and evaluation within educational settings Fronteirs in Education, 25 July 2018

Perry, B. (2018) Twitter discussion on 21/06/18

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Why I worry about the ACE-aware movement's impact

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Practitioners across a range of disciplines who work carefully and respectfully and operate within the bounds of their professional registrations are perhaps, like me, feeling slightly ill-at-ease in the wake of the recent "ACE-aware" movement.

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ACE-Aware Nation (sometimes known as the ACEs "movement") has enjoyed significant attention in Scotland due to screenings around the country of a promotional film ( Resilience) and a conference held in September 2018.

"ACE" stands for adverse childhood experience. Tes Scotland has recently published two pieces on the topic that offer a good summary of the emerging debate: Why I worry about the ACE-aware movement's impact, by educational psychologist Whitney Barrett, and a response by consultant Suzanne Zeedyk, entitled: Childhood trauma: Why I celebrate the ACE-aware movement's impact.

This begs the question: should we worry about ACEs or should we celebrate?

I aim to put forward something of a middle ground between these perspectives. I refer to the ACEs "campaign" as opposed to "movement", as I believe this is more accurate. I identify elements of the campaign that are welcome, and others that should give cause for concern. I stop short of proposing a firm conclusion about the campaign. Instead, I suggest an alternative to the deficit-based lens of "adverse childhoods", and a positive way forward for the campaign.

Should we worry or celebrate?

While it seems contradictory and even distasteful to celebrate anything to do with child abuse and trauma (or indeed to describe these experiences as "ace"), certain elements of the campaign deserve a cautious welcome. It has led to an additional focus on the long-term impact of childhood distress and trauma. It seeks to foreground the roles of love and compassion in childhood and in our relationships with children. It encourages practitioners to look beyond children's "misbehaviour" and to consider instead that this might be a sign that they are struggling with something. For some people, ACEs represent a new way of understanding and talking about abuse. These contributions are important.

To come to a view on the ACEs campaign, I suggest considering the following:

The aims of the campaign;

The concepts used, especially adverse childhood experiences;

The "science" of ACEs;

The practice of ACEs "scoring".

Aims

Organisations such as NSPCC have been working tirelessly for many years, as have many other organisations and professionals, in the areas of preventing abuse, supporting families, enabling children to speak out and researching the prevalence of abuse. Mobilising a group of supporters around these aims is welcome, but other than that, what precisely is the ACEs campaign contributing? Is it claiming that previous attempts have failed and that it is here to save the day, as Suzanne Zeedyk's article seems to suggest? Or does it seek to build on what is already being done? Is the campaign claiming that its approaches are relevant universally to all children, regardless of context and personal histories? The main purpose seems to be about raising awareness, but what kind of awareness, and what should we DO with that awareness?

Concepts

The ACEs campaign is suddenly dominating discussions about childhood, adversity, abuse, neglect and trauma in Scotland. It is important to discuss these issues, but the usage of these terms should be specific and clear. The campaign risks conflating these concepts using the umbrella term of adverse childhood experiences. Referring to "adverse experiences" risks understating the horrors of abuse and neglect. It is abuse - why call it anything else? In addition, the term risks suggesting that adversity of any kind is bad or traumatic. While abuse and neglect should always be considered fundamentally wrong, traumatic and preventable, the same cannot always be said for adversity. Everyone will experience adversity at some point and there is often strength and hope to be found in it. Our responses to adversity can nurture resilience and loving relationships while also defining our identities.

Science

The ACEs campaign raises awareness of important scientific studies, but it only cites studies that back up its claims. There is no recognition or discussion of the inherent contestability of ACEs research, especially the original ACEs study (Felitti et al, 1998). A select committee response detailing the problem with ACEs provides a critical summary from a social science (as opposed to medical) perspective, concluding that the "...further rolling out of the ACEs approach would be a very dangerous way to proceed" (Edwards et al, 2017). This may be frustrating for those looking for straightforward answers, but these are serious criticisms that cannot be brushed aside.

Scoring

The ACEs "scoring" tool (a checklist that provides an ACEs score between one and 10) is designed for population-level epidemiological research. It was never meant for use in clinical, educational or public settings. Nonetheless, the ACEs campaign appears to explicitly advocate its use without any obvious caveats. The promotional film Resilience shows rooms full of people calculating their "ACE score", which involves thinking about whether they experienced abuse, neglect or "dysfunction" in childhood. There is little exploration of the extremely problematic ethics of this practice. The very act of asking people this question could be a source of trauma.

Asking children about this, without their consent, is completely unethical. It would force them to reflect on something that they might not even understand or remember. Assigning an ACE score to a child without their knowledge or participation is equally problematic. How would a practitioner know if their assessment is accurate or if the child agrees with it? What would happen with that information? This is a direct violation of children's rights to privacy, consent and participation among others, and it risks perpetuating hierarchical adult-child relationships that can inadvertently lead to unjust or discriminatory practices (Davis et al, 2014).

Adults cannot simply "tell" children what their identities are or stand in paternalistic judgement about the adversity in their lives. The ACEs campaign should provide a clear message as to whether it endorses ACEs scoring - but it has not done so. I suspect this is because scoring is a fundamental part of the ACEs methodology and powerful proponents of the ACEs approach in the US support universal scoring and screening. There are also examples emerging of ACEs scoring being utilised in Scotland, which is very worrying. Even if scoring isn't used, the campaign advocates that practitioners can and should make judgements about the quality of life experienced by children and families. This risks perpetuating a "blame and shame" culture that holds children and families completely responsible for their circumstances, leaving unjust social inequalities beyond challenge.

At best, these worries are symptomatic of a series of mistakes, for which the ACEs campaign can be forgiven. It is easy to mistake the emperor's new clothes for a silver bullet. Jumping on a bandwagon out of desperation for solutions to intractable problems is entirely understandable. However, there are deliberate and calculating attempts to circumvent critique by promoting a campaign using "common-sense" language of relationships and cuddles, gaining support (practical, financial or political) and creating a profitable "ACEs industry" in Scotland. My hope is that the former explanation is closer to the truth and that the campaign is listening and reconsidering its message.

Hopeful childhoods

What would happen if we were to turn this discourse on its head by talking about "hopeful childhoods" instead of "adverse childhoods"? Could we take a positive and affirmative stance, coming from a place of love and hope as opposed to fear and adversity? This is not to say that we should ignore childhood adversity or deny that it exists. Many children experience adversity, but their childhoods and lives do not necessarily need to be defined by it. Empathy, love, compassion and social justice should not be situated within a context of adversity and anger. This only serves to undermine and debase these precious principles. Doing so does not make us more "aware", it blinds us to more hopeful alternatives. Instead of starting an angry battle cry of "we have to do something!", we can subtly shift our thinking to a stronger and more hopeful perspective of something can be done.

A way forward?

If promoters of the ACEs campaign were willing to recognise and discuss critical perspectives on these issues, that would be worth celebrating. We all want the same thing, after all, which is to prevent harm coming to children, to improve their circumstances, to establish trust and loving relationships. In doing so, we should consider the possibility of unintended and potentially harmful consequences of evangelical campaigning.

I would like to suggest two things that could start a productive dialogue. Firstly, we could recognise the practices that are currently working for children and build on the strengths of those endeavours. Secondly, we could recognise that children have complex views of social justice and adversity, and that their perspectives should be front and centre of any discussion about childhood - adverse, hopeful or otherwise (Davis et al, 2014).
Gary Walsh is a PhD researcher at the University of Glasgow School of Education
References

Davis, J, Hill, L, Tisdall, K, Cairns, L, McCausland, S (2014), "Social justice, the common weal and children and young people in Scotland", The Jimmy Reid Foundation

Edwards, R, Gillies, V, Lee, E, Macvarish, J, White, S, Wastell, D (2017), "The Problem with ACEs", submission to the House of Commons Science and Technology Select Committee inquiry into the evidence-base for early years intervention (EY10039)

Felitti, VJ, Anda, RF, Nordenberg, D, Williamson, DF, Spitz, AM, Edwards, V, Koss, MP and Marks, JS (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 Preventive Medicine, vol. 14, no. 4, pp. 245-258

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The ACEs campaign: cause for worry or celebration?

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ACE-Aware Nation (sometimes known as the ACEs "movement") has enjoyed significant attention in Scotland due to screenings around the country of a promotional film ( Resilience) and a conference held in September 2018. "ACE" stands for adverse childhood experience.

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Almost half of children in the UK have experienced at least one adverse childhood experience (ACE) and one in 10 have experienced four or more.

ACEs are traumatic experiences that occur before the age of 18 and are remembered by survivors throughout the rest of their lives. Such experiences include emotional, sexual and physical abuse, and being raised in a household where there is alcohol misuse, mental illness, domestic violence, parental separation, drug addiction or familial imprisonment.

Evidence shows that children who experience adversity in childhood are more likely to perform poorly in school, develop anti-social and health-harming behaviours, be involved in crime, suffer poor mental and physical health. And they are less likely to become productive members of society. Often, the greater the number of ACEs, the greater the repercussions.

What the research says: The ACEs campaign - cause for worry or celebration?

Opinion - for: Why I celebrate the ACE-aware movement's impact

Opinion - against: Why I worry about the ACE-aware movement's impact

Personally speaking, I am in that "more than four" category - remarkably, I have turned out all right, but it was not easy. I was fortunate to have a few great teachers and an education system that accommodated my challenging behaviour.

These teachers had the time to eat their lunch with me, teach me how to knit and play the guitar, and channel my ability to throw chairs across the room into throwing a javelin for the county. And they had the freedom to say "go and run around the field for 15 minutes" when they could see I was getting ready to fight.

Because of their kindness, and despite a few exclusions, I passed some exams and went on to train as a teacher; I then spent the next 20 years trying to do for my children what those teachers had done for me.

But as I moved from school to school, I became increasingly frustrated with the rules and regulations that prevented me from doing what I knew was necessary to meet the needs of these children.

Hopefully, this is beginning to change. Information about ACEs is appearing everywhere in the UK. Scotland is determined to become the first ACE-Aware Nation, Wales is hot on its heels, and so too are areas in Ireland and England.

Traumatised pupils are 'less able to learn'

People are discussing ACEs on social media - many are grateful for how this knowledge helps them to make sense of their lives, others are unhappy about labelling people with ACE "scores". Surely, though, what is most important is that we are talking about the extent to which many of our children and young people are suffering.

Children with a high number of ACEs are in often in pain. They are struggling to regulate themselves, their emotions and their behaviour. They don't feel safe or as though they belong. They have few positive relationships. They find it hard to trust others and they are less able to learn.

This is a challenge that cannot be resolved quickly and, as is so often the case, schools are well-placed to begin this work. But addressing ACEs requires a whole-school approach and often a substantial shift in thinking.

Everyone in the school - including lunchtime supervisors, the caretaker, office staff and teachers - needs to understand that behaviour is communication. And that, often, aggression, daydreaming, defiance, rejection and withdrawal are actually hiding fear, distress, pain, confusion and worthlessness.

So, in response, schools need to become ACE-aware, attachment-aware and trauma-informed to create safe environments for our children, and build supportive and trusting relationships with them. Schools need to teach these young people the skills to regulate their disregulated bodies so that they can begin to manage their emotions and behaviour, and get to a place where they are ready to learn.

Policies and practices need to evolve to accommodate and help these children heal rather than causing them further harm by excluding and rejecting them. Schools need to understand the impact working with these children has on staff and take care of them accordingly. Both children and adults need to cultivate resilience, and schools need to move towards restorative practices rather than punitive behaviour policies.

Of course, this will not happen overnight - we need to be in it for the long haul. But there is plenty of research to show that a shift like this in our thinking and practice will lead to better outcomes for our children, their families and our teachers, both in the short and long term.
Lynn Miles is a lecturer in education at Teesside University, which offers related ACE short courses, whole-school CPD and, from September 2019, an education MA in trauma-informed practice

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How to support pupils with adverse childhood experiences

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Almost half of children in the UK have experienced at least one adverse childhood experience (ACE) and one in 10 have experienced four or more. ACEs are traumatic experiences that occur before the age of 18 and are remembered by survivors throughout the rest of their lives.

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Tackling child poverty: Actions toprevent and mitigate child povertyat the local level

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Tackling child poverty: Actions toprevent and mitigate child povertyat the local level

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Report by What Works Scotland

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Police are the latest group to hail an index of child trauma that offers a key to health and behaviour. But is it good science, asks Chris Marshall

In the mid-1980s, doctors running a weight loss programme at a clinic in San Diego happened upon a startling discovery.

Struggling to understand why successful slimmers were quitting, lead physician Dr Vincent Felitti began interviewing the leavers and found many had experienced sexual abuse in childhood.

His findings led to a conclusion that would have major implications for public health - overeating was being used unconsciously as a protection from trauma suffered early in life.

Contrary to all the medical evidence, it seemed obesity did provide benefits for some; it helped people deal with physical, sexual or emotional experiences they had undergone as children.

It was out of Felitti's research that the Adverse Childhood Experiences (ACEs) Study was born. Between 1995 and 1997, 17,000 Californians were surveyed on their physical health alongside questions about their childhoods.

The study found that as the number of ACEs increased, so did the incidence of depression, alcoholism, promiscuity and suicide attempts in later life.

A bold interpretation of the results was that trauma endured during childhood was the main determinant for the health and wellbeing of adults.

More than 20 years on from that landmark study, the concept of ACEs has moved centre stage.

The idea has been enthusiastically adopted by the Scottish Government, teachers, psychologists and even Police Scotland.

Supporters speak of making Scotland the world's first "ACE-aware" nation, believing negative childhood experiences can help explain everything from smoking to criminality.

But while few deny that childhood trauma can have a profound and long-lasting impact, there is growing controversy over the adoption of the ACEs agenda, which some experts argue fails to take account of socio-economic conditions and can unfairly stigmatise children.

It is claimed that ACEs have been seized upon as a "magic bullet" in an era when teachers, social workers and police officers have been left bereft by the impact of austerity, desperately reaching for something, anything, to help tackle deep-seated social problems.

According to the Centers for Disease Control and Prevention, the US public health institute which carried out the original study, there are 10 ACEs.

They include emotional or physical neglect; emotional, physical or sexual abuse; divorce; domestic violence; imprisonment of a family member; living in a household where there is drug or alcohol abuse; or where there is experience of mental illness.

By adding together the number of areas of adverse experience suffered before a person's 18th birthday, it is possible to attribute to someone an "ACE score".

The Scottish Government cites research from Wales which suggests people who experience four or more ACEs are four times more likely to be a problem drinker, three times more likely to develop heart disease, 15 times more likely to commit violence and 20 times more likely to go to prison.

Developmental psychologist Dr Suzanne Zeedyk, an honorary fellow at Dundee University, has been at the forefront of promoting awareness of the impact of childhood trauma.

She believes growing Scottish interest is the result of a grassroots movement driven by social media which has seen teachers, social workers and police officers come together for screenings of an American documentary, Resilience, which explores the impact of stress on the body.

She estimates that upwards of 20,000 people have watched the film, 200 alone at showings put on by schools in West Lothian last week.

"What's important from the ACEs research is not those 10 examples of adverse experiences but the understanding that fear changes your biology," she says.

"There has been a light bulb moment from the ACEs study. We have known that a troubled childhood can make your adulthood difficult, people intuitively get that.

"What we thought was that it led to mental health difficulties, that you'd be more likely to be depressed or attempt suicide, that you might find relationships difficult.

"But most people are surprised to learn that childhood distress makes it more likely you'll have a heart attack, that you'll get cancer, that your risk of diabetes is increased. Most people are surprised by that - it hasn't been part of our cultural awareness."

There is indeed growing evidence that early and prolonged trauma can have a devastating impact on a child's biological development.

Exposure to so-called "toxic stress" is known to reduce neuro-connections in parts of the brain responsible for learning and reasoning.

According to researchers at Harvard University, in cases of chronic abuse - especially during early, sensitive periods of brain development - the parts of the brain involved in fear, anxiety, and impulsive responses can overproduce neural connections while those regions dedicated to reasoning, planning, and behavioural control go into decline.

The science indicates that the mere presence of a loving adult can prevent elevations of the stress hormone cortisol in toddlers, providing a powerful buffer against this neurological onslaught.

"We are talking about childhood distress in a way we have not done before," says Zeedyk. "I see this as a real opportunity for our country to pay closer attention to distress. It's ACEs that have got us interested, it has engaged people's interest.

"Some of my colleagues are worried that the framework of ACEs could distract the government from looking at poverty. In other words, if we blame the parents, it takes our eyes off poverty. But I think ACEs lets us look at both, I don't think it makes us choose."

The challenge for the ACE-aware and the "trauma-informed" is how they now use that information to alleviate childhood suffering and treat adults still dealing with the impact of abuse earlier in life.

One example of what the future might look like comes from an unlikely source.

Earlier this month, officers from Police Scotland's Ayrshire division told a meeting of the Scottish Police Authority how the unit had become trauma-informed at a cost of less than £5,000.

Officers were shown the Resilience documentary in the hope that learning about the impact of adverse experiences in childhood will help inform the work of a force which estimates that 80 per cent of its work relates to non-criminal matters.

To an ageing population - growing numbers of them with dementia - add the impact of cuts to mental health provision and you're left with police officers fielding increasing numbers of calls relating to missing persons and people in distress.

Society's growing awareness of historical sexual abuse has also significantly contributed to the caseload as more adults come forward to report the trauma they have been living with for decades.

"More and more officers are dealing with homelessness, eviction, mental health and poverty," says Ayrshire divisional commander Chief Superintendent Paul Main.

"Unless we understand the life experiences people have or the trauma they've suffered, we're not going to deliver as good a service as we should."

Main uses the example of a man who was arrested and due to appear in court. Police officers had taken the time to ask questions and found out the man had an addiction worker who was able to "scoop up" his client when he left court.

"Instead of that person coming out of court and into a cycle of crime, alcohol or drugs, they had someone who cares about them and could take care of them," says Main.

The chief superintendent likes to repeat the mantra "Adversity is not destiny", knowing that just because a person has had a tough start in life doesn't mean they will become a career criminal.

"We could keep locking people up and throwing away the key and they would come out and commit more crime. I don't think that's the right approach. We absolutely need to arrest and incarcerate a small group of people some of the time, but for the vast majority, the best way of keeping people safe is to find ways of preventing crime or the reasons for the crime in the first place."

But amid all the positivity there are those sounding notes of caution, particularly about the dangers of overlooking the pernicious effects of poverty.

Research published last week by Edinburgh University found two-thirds of children in Scotland have suffered an adverse life event by their eighth birthday, while one in 10 have experienced at least three such traumatic events in their lifetime.

Dr Louise Marryat, who carried out the research, says her study shows those living in disadvantaged circumstances are particularly at risk.

"Up until now, there's been a lot of talk about adversity being experienced across the population, which is true. However, these results seem to be suggesting it is particularly concentrated in children who live in low-income households and who experience other forms of disadvantage," she says.

"It's a really important thing to keep in mind that this isn't a deterministic thing - it's not the case that you experience ACEs and you will end up with these outcomes.

"It should be used as a tool on a population level, not for individuals. People who experience four or more ACEs are at higher risk of developing physical and mental health conditions, but it's not inevitable."

Marryat says there is some anecdotal evidence of ACE scores being used to screen children in schools.

"I think we should be concerned if it's being used in that way," she adds. "We know how difficult it is to get access to child and adolescent mental health services as it is. If the support isn't there, I think that's quite worrying.

"There is a view, I'm not necessarily saying it's my view, that our resources are so limited at the moment that it's very hard to deal with these big issues and the ACE scale makes it feel like we're doing something.

"I think the people that are proposing this are doing it with the best intentions. People genuinely want things to be better for children in Scotland. Whether this is the best approach for that, I'm not sure I agree."

Others are far more critical. The Problem With ACEs was an academic paper submitted to the House of Commons' Science and Technology Committee's inquiry into early years intervention.

Its authors said "alarm bells should ring" when advocates begin talking in evangelical terms about ACEs.

The paper states: "These are often social problems which have been occurring and been responded to by policy-makers and politicians for at least 150 years: crime, drunkenness, mental health problems, violence. This is not to say that nothing can or should be done but that there is no such thing as a magic bullet intervention."

Rosalind Edwards, a professor of sociology at Southampton University and one of the paper's authors, has a number of misgivings about the way the original ACE Study is now being applied.

"The studies that were done that people rely on to show that there are adverse outcomes from adverse circumstances, they were scientific studies done at population level," she says.

"They talk about the risk, the probability that people will have these bad outcomes in later life. They cannot be applied to an individual. You cannot point to an individual child and say they are having dreadful things happen to them so they will have dreadful outcomes later in life. But that's happening because it's being translated into tick box protocols where teachers or social workers are encouraged to tick how many adverse circumstances children have and then they are given an ACE score. That is a fundamental misunderstanding of what you can do on the basis of the science."

Edwards worries that ACEs are being applied in a deterministic way - she notes that a person can have no ACEs and still turn out to be "quite dysfunctional". The opposite is also true.

"I don't wish to say that people don't have goodwill in implementing ACEs and it may give the police, teachers and social workers something firm to hold on to, but actually they are grasping at a straw person.

"I would encourage them to row back from it. You need to understand what the science is telling you and what it is not telling you. It's tough in times when finances are difficult, but actually just investing in human services and a humane approach is what you need. You don't need ACEs to do that."

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ACEs: Light bulb moment or magic bullet for social ills in Scotland?

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Police are the latest group to hail an index of child trauma that offers a key to health and behaviour. But is it good science, asks Chris Marshall In the mid-1980s, doctors running a weight loss programme at a clinic in San Diego happened upon a startling discovery.

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Children from Scotland's most deprived areas are more than twice as likely to have concerns raised about their development, official figures have indicated.

According to analysis published by ISD Scotland of its 27-30 month health review, 22 per cent of children from the poorest areas had a concern raised about their development.

In the review, health visitors were asked to assess a number of areas of development including speech and communication, problem solving, personal and social skills, and behavioural development.

Just over 20 per cent of children in the most deprived areas were recorded as having at least one developmental concern, with speech, language and communication or emotional or behavioural issues, noted as being the most pronounced.

This compares to less than 10 per cent of children in the least deprived areas recorded as having any concerns over their development. The overall number of children recorded in the study as having a concern raised over their development has decreased since the health review was first introduced six years ago.

Scottish Labour MSP Monica Lennon said: "Nicola Sturgeon promised Scotland's children the best start in life but instead poverty is increasing and is harming the life chances of Scotland's poorest children.

"These startling poverty-related health inequalities are failing children.

"Scottish Labour shares the Scottish Government's aspiration for Scotland to be the best country to grow up in so we are bitterly disappointed that the ambition is not backed up with investment in children and young people.

"The SNP government has failed to tackle poverty-related health inequalities after over a decade in power."

In 2013-14, the first year of the review, a total of 19 per cent of children from 43,102 reviews had been recorded as having had concerns raised.

This had dropped to a total of 15 per cent of 50,600 children in the latest figures for 2017-18.

A Scottish Government spokeswoman said: "We welcome these figures and acknowledge the benefit of having a means to identify issues at an early age and put support in place. The fact 29 per cent of children who were looked after were more likely to have a developmental concern recorded against 15 per cent of non-looked after children is not unexpected. It reflects the broader vulnerability of this group to adverse childhood experiences."

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Development of children in deprived areas twice as likely to raise issues

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Children from Scotland's most deprived areas are more than twice as likely to have concerns raised about their development, official figures have indicated. According to analysis published by ISD Scotland of its 27-30 month health review, 22 per cent of children from the poorest areas had a concern raised about their development.

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A leading psychologist and expert on childhood trauma has said the debate around screening children as young as four for psychopathic traits "misses the point".

Dr Suzanne Zeedyk has responded to a controversial opinion piece last week by Dr John Marshall, a clinical and forensic psychologist who assessed Aaron Campbell, the teenage murderer of six-year-old Alesha MacPhail on the Isle of Bute.

Marshall, the head of psychological services at the State Hospital, Carstairs, said children whose behaviour was causing problems raised by parents and services should be screened for "psychopathic traits" including cruelty to other children and animals.

Campbell, who was ordered to serve a minimum of 27 years of a life sentence, has lodged an appeal against his sentence. The 16-year-old was described by judge Lord Matthews as a "cold callous, calculating, remorseless and dangerous individual".

Zeedyk told Scotland on Sunday that there was a cultural tendency to search out "monsters" rather than getting to grips with ongoing childhood development.
Dr Suzanne Zeedyk: Expert misses the point on child screening
I know Dr Marshall spoke in an exasperated tone of the ACEs movement

She said this left children at a greater risk of harm and the real concern was that Scottish culture did not recognise sufficiently the importance of a warm, loving secure relationship for children.

Zeedyk is at the forefront of a grassroots movement looking into Adverse Childhood Experiences (ACEs) that grew out of a seminal scientific US study done in the 1990s.

The study found that as the number of ACEs increased, so did the incidence of depression, alcoholism, promiscuity and suicide attempts in later life.

The idea is based on a theory that trauma endured during childhood was the main determinant for the health and wellbeing of adults.

The concept of ACEs has been widely adopted by the Scottish Government, teachers, psychologists and Police Scotland.

Zeedyk said: "In his statement, Dr Marshall spoke of the importance of warm relationships for young children's development, and he talked of the impact of early intervention. That puts [us] on the same page. We are all speaking to the fundamental importance of relationships to human development.

"I know, though, that Dr Marshall spoke in an exasperated tone of the ACEs movement. He thinks that the 'gods of ACEs' are leading professionals [especially social workers] to focus on traumatic events in children's lives at the expense of focusing on genetic factors.

"He is essentially situating the issue within the age-old framework of nature versus nurture."

Zeedyk said Marshall's statement had drawn condemnation from many in the child welfare arena, with the Centre for Youth and Criminal Justice releasing a statement arguing that his proposal for universal screening was supported neither by research nor his professional association's guidelines.
Read the full text of Dr Suzanne Zeedyk's comments at https://bit.ly/2FYK9wR

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Nature v nurture battle rages over 'psycho' children

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A leading psychologist and expert on childhood trauma has said the debate around screening children as young as four for psychopathic traits "misses the point". Dr Suzanne Zeedyk has responded to a controversial opinion piece last week by Dr John Marshall, a clinical and forensic psychologist who assessed Aaron Campbell, the teenage murderer of six-year-old Alesha MacPhail on the Isle of Bute.

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‘Steeling’ Young People: Resilience and Youth Policy in Scotland

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‘Steeling’ Young People: Resilience and Youth Policy in Scotland

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Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland

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Polishing the Diamonds: Addressing Adverse Childhood Experiences in Scotland

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Report by Scottish Public Health Network (ScotPHN)

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Growing up in disadvantage: a systematic review of the qualitative evidence

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Growing up in disadvantage: a systematic review of the qualitative evidence

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Growing up in disadvantage: a systematic review of the qualitative evidence. - PubMed - NCBI

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Child Care Health Dev. 2004 Nov;30(6):679-89. Research Support, Non-U.S. Gov't; Review; Systematic Review

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Longing to belong: children in residential care and their experiences of peer relationships at school and in the children's home

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Longing to belong: children in residential care and their experiences of peer relationships at school and in the children's home

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Resilience literature has stressed the potential of both children's educational experiences and their friendships to act as protective factors against adversity. However, less is known about how children living with adversity navigate these ‘everyday’ aspects of social terrain and the particular challenges that they face. This paper explores the meaning and experience of peer relationships to one group of children living in residential care in Ireland.

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Please check your email for instructions on resetting your password. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account.

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Marryat L, Frank J: Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study

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Marryat L, Frank J: Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study

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This paper sets out to determine the prevalence of ACEs at age 8 in a recent prospective birth cohort and examine associations between risk factors in the first year and cumulative ACEs.

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Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study

Abstract

Background and objectives Adverse childhood experiences (ACEs) have been associated with a range of poorer health and social outcomes throughout the life course; however, to date they have primarily been conducted retrospectively in adulthood. This paper sets out to determine the prevalence of ACEs at age 8 in a recent prospective birth cohort and examine associations between risk factors in the first year and cumulative ACEs.

Design This study uses the Growing Up in Scotland Birth Cohort 1, in which children born in Scotland in 2004/5 were identified using Child Benefit Records and followed up for 7 years (n.3119). ACE scores and sample characteristics were calculated and described. Logistic regression models were fitted to explore associations between risk factors (sex, mother's age and education, household income, area level deprivation and urban/rural indicator) and ACE scores.

Results Seven ACEs (or proxies) were assessed: physical abuse, domestic violence, substance abuse, mental illness, parental separation, parental incarceration and emotional neglect. Instances of sexual abuse were too few to be reported. Emotional abuse and physical neglect could not be gathered. Around two-thirds of children had experienced one or more ACE, with 10% experiencing three or more in their lifetime. Higher ACE scores were associated with being male, having a young mother, low income and urban areas.

Conclusions Using prospective data, the majority of children born in 2004/2005 in Scotland experienced at least one ACE by age 8, although three ACEs could not be assessed in this cohort. ACEs were highly correlated with socioeconomic disadvantage in the first year of life.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

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What is already known on this topic?

Adverse childhood experiences (ACEs) have been found to be commonly reported across adult populations. Limited evidence suggests that higher levels of ACEs are found among adults who had a younger mother and who live in more deprived neighbourhoods.

Lower levels have been seen in older populations, white or Asian populations and among graduates.

What this study hopes to add?

Introduction

The adverse childhood experiences (ACEs) scale was first explored with US adults, who were asked a series of questions covering childhood psychological, physical and sexual abuse and household dysfunction. Around half (52.1%) reported experiencing at least one item. 1 Evidence from England and Wales, respectively, showed similar results. 2 3 A study from New Zealand exploring ACEs in the 1970s suggested that c.58% in a prospective study and c.65% in a retrospective study experienced at least one ACE. 4

Living in adverse socioeconomic circumstances during childhood has a demonstrated association with later physical and mental health outcomes. 5-7 ACEs go beyond this to look at other adversities, for example, abuse and parental imprisonment. While there is likely to be a substantial overlap with deprivation, this is generally unknown, although evidence of associations with individual measures does exist. 5 8 9 The original ACE study included only adults with private health insurance, suggesting that, as adults, this group were relatively affluent. 1 Neighbourhood deprivation has been associated with increased levels of ACEs; 10 however, Bellis et al only found deprivation to be associated with having four or more ACEs. 11 Higher levels of ACEs have been associated with having a younger mother, 11 while lower levels have been found among older people, white or Asian people and graduates. 1

ACEs have been linked to adverse outcomes in childhood and adulthood: 1 2 12 13 they have been associated with poorer self-rated health, premature mortality, suicide attempts, depression, ischaemic heart disease, cancer, chronic lung disease, skeletal fractures, liver disease, fetal death and chronic obstructive pulmonary disease. 1 13-17 ACEs have also been associated with risky lifestyle behaviours, for example, drug and alcohol use, smoking and high numbers of sexual partners 1 as well as job, financial and reproductive problems. 15 They have been linked to multimorbidity in adulthood. 1

Despite the current interest in ACEs and their seeming importance in relation to subsequent outcomes, we know little about modern ACEs. The capturing of ACEs in the general population is difficult and relies on retrospective data collected in adulthood. The aims of this paper are to explore to what extent ACEs could be determined using prospective cohort data and what prevalence levels look like in a recent population. This approach allows exploration of the predictors of ACEs, normally not available in retrospective data.

Method

Child and parent interview data were taken from the first seven waves of the Growing Up in Scotland (GUS) study, covering the first 8 years of the child's life. This study, funded by the Scottish Government, tracks the lives of children from birth through to their teenage years and beyond and collects a wide range of information, including cognitive, social, emotional and behavioural development, health and well-being, childcare, education and parenting and social networks. The full design has been reported elsewhere. 18 The sample was taken from child benefit records, which at the time of sampling included 97% of the Scottish population with children. Data zones (the key small-area geographic statistic in Scotland, each containing 500-1000 people and nested within Local Authorities) were aggregated until each area had an average of 57 live births per year, based on the previous 3 years of data, which was estimated to provide the required sample size. These primary sampling units were then stratified by Local Authority (n.32) and then by Scottish Index of Multiple Deprivation Score (a measure of relative area level deprivation), before 130 points were chosen at random. Prior to final sampling, the Department of Work and Pensions removed any 'sensitive cases' (eg, where there had been a death in the immediate family) and any cases which had been sampled in the previous 3 years (c.5%). They then sampled all babies within the selected points which met the date of birth criteria. In cases where more than one child met the criteria, one child was selected at random. Where children were found not to be living with their natural parent, they were followed up where possible in foster care or kinship care. Sweep 1 took place in 2005/2006 when the children were 10 months old with 5217 children, comprising 81% of the eligible children. 19 At Sweep 7, 3456 children remained (66% of sweep 1 children), with a target interview date of 94.5 months old. 18 Table 1 details the missing cases. Cases were only included were the participant had the relevant ACE and demographic data, of which there were 3119 (90.2% of all Sweep 7 subjects). Exploratory analyses indicated that respondents missing data at this stage were more likely to be younger mothers, those living in more deprived areas and those in urban areas. Cases without full data were not used: no imputation was used. Longitudinal weights, produced by the survey team at ScotCen, were used, and the stratification of the sample was accounted for using the Complex Samples module within SPSS24. 20 Full information on weighting can be found in the data user guide. 18

Data from GUS were mapped onto the ACE questions (online supplementary table 1) and sociodemographic information from the first sweep were combined into one dataset. Since ACE-related questionnaire items were asked inconsistently throughout the seven sweeps of the study, an 8-year cumulative incidence of ACEs was derived by summing the ACEs present for each child throughout the study period. Seven ACEs (or proxies for them) were available: physical abuse, domestic violence, substance abuse, mental illness, parental separation, parental incarceration and emotional neglect. Information on Emotional abuse and Neglect was not available. Sexual abuse was reported in response to an open-ended question; however, personal communications with the survey team revealed that fewer than five participants had responded positively to this, and it was thus excluded.

Ethics

Each sweep of data collection was subject to medical ethical review by the Scotland 'A' MREC committee. All parents interviewed (and Children, for the child interview) gave their informed consent prior to inclusion in the study. The current analyses were subject to ethical review in the University of Edinburgh.

Analyses

Binary variables of one or more ACE (vs none) (1+ ACE) and three or more ACEs (vs <3) (3+ ACEs) were derived. Three or more ACEs were explored, rather than four or more, due to the number of ACEs assessed being fewer and children having had less time to accumulate them. Sociodemographic data were described and Spearman correlations between them were explored. All correlations were of a weak to medium strength (online supplementary table 2).

Multiple univariable logistic regression models were fitted predicting the odds of having 1+ and 3+ ACEs, respectively ( table 3). Predictors were taken from the current literature: sex, ethnicity, income, age of mother at the birth of the first child and mother's educational qualifications. Where univariable associations reached the criterion of p<0.1, these variables were put into the multivariable model.

Patient and public involvement statement

This paper uses secondary data analysis of the first seven sweeps of the GUS study. The original study was designed in conjunction with the Scottish Government, academics and third sector organisations. The current analyses have had input from the Scottish Government ACEs team, have been presented and discussed at an NHS event as well as being discussed with a variety of third sector organisations representing and working with people who have experienced ACEs. Further dissemination of the work is planned to practitioners working with people who have experienced ACEs as well as to the general public through social media and national media.

Results

Around two thirds (65%) of children experienced 1+ ACE, with 10% experiencing 3+ at age 8 ( figure 1).

The most common ACEs were parental mental health problems (35.4%) and having parents who were separated or divorced (32.1%). The proportion reporting frequent physical punishment was high (22.2%). Few children experienced parental imprisonment (0.4%) ( table 2).

ACEs varied by household income quintiles: 1% of children in households in the top income quintile had 4+ ACEs, compared with 10.8% in the lowest income group ( table 3).

Boys were more likely to experience 3+ ACEs, as were those with younger mothers, mothers with fewer educational qualifications and children living in more deprived areas. A higher proportion of children from a white UK background, compared with other ethnic groups, experienced 3+ ACEs, although the low proportion (4.3%) of children from non-white-UK backgrounds limited the power of this comparison. Children in urban areas were more likely to have experienced a higher number of ACEs (3.4% vs 1.3% in rural areas).

Independent associations were explored between risk factors in the first year of life and having 1+ or 3+ ACEs, respectively. The multivariable model indicated that risk factors predicting having 1+ ACE at age 8 were living in a lower income group, in particular living in the lowest income quintile (OR 7.11); being male; having a mother with lower educational qualifications; having a mother who was under 20 or over 40 at the birth of her first child; living in an area with higher levels of deprivation or in an urban area ( table 4).

The model predicting having 3+ ACEs at age eight was very similar. In this multivariable model, maternal educational qualifications did not meet our criteria for statistical significance, although it is worth noting that the ORs were similar to the previous model. Once again, the strongest predictor of experiencing 3+ ACEs was living in a household in the lowest income quintile, where odds were 5.7 times higher ( table 4).

Discussion

By 8 years, around two-thirds of children had 1+ ACE, with 1 in 10 children experiencing 3+. Results indicate that children living in more disadvantaged circumstances were more likely to experience ACEs than their more privileged peers.

Strengths

This paper is unique in using a range of prospective data on ACEs in a current generation of children. GUS covers a representative sample of children from Scotland, providing large enough numbers to explore ACEs by subgroups, combining a mixture of parental and child-reported data, giving a rounded picture of ACEs which have occurred. The inclusion of family background data allows us insight into what early predictors are associated with having higher odds of experiencing ACEs. In addition, families were asked to answer a range of questions about their lives, rather than a specific questionnaire about ACEs: Felitti et al found that respondents to the ACE questionnaire were slightly more likely to have reported sexual abuse in a separate questionnaire, suggesting that there may be a bias within the original ACE studies towards people who had experienced ACEs. 1

Weaknesses

The original ACE questionnaire has not yet been included in GUS and so some proxy information had to be used, which may not accurately reflect the ACE questionnaire. Two ACEs (emotional abuse and neglect) were not able to be assessed through the GUS questions. In addition, the proportion of parents reporting sexual abuse was so low that we were not able to include this. It is possible that social desirability may lead to some parents not disclosing where ACEs had occurred and, furthermore, if ACEs, such as abuse, happened outside the home, parents may not be aware that they have occurred. All these factors are likely to lead to this study underestimating the prevalence of ACEs. Despite the sample being representative of the population of children in Scotland, some particularly sensitive cases were removed prior to sampling by the Department for Work and Pensions, which likely include children who suffered adversity within the first 8-9 months. GUS suffers from differential attrition, whereby children from the most disadvantaged backgrounds are disproportionately lost to follow-up. 21 Longitudinal weights do make up for this to some extent.

The proportion of children with 1+ ACE was substantially higher than most other retrospective studies, in contrast to findings from New Zealand. 1-4 There are various factors which might explain this difference. Differences in the way questions are phrased and proxies used are likely to affect prevalence reported. Second, there are issues around recall: data in the latter studies were collected up to 40 years after the events took place, compared with continuous collection in GUS. Hardt and Rutter concluded that reports of ACEs in adulthood involve a 'substantial rate of false negatives' due to a lack of very early childhood memory, mood congruent recall biases and the fact that people are only able to recall what they were aware of at the time 22-for example, some parents keep the incarceration of a parent from their children. 22

Cohort effects may also play a role: retrospective studies look back at childhoods between the 1950s and 1970s, where parenting and societal norms often differed from the present day: harsh corporal punishment was far more frequent historically and still varies substantially between countries. 8 It is noteworthy that the New Zealand cohort with the most recent data (from childhoods in the 1970s-1980s) displayed the most similar results to the GUS study. 4 Access to data on cohort differences in ACEs within studies is somewhat limited, although one retrospective study, which looked at four cohorts between 1900 and 1978, found evidence that the proportion of children with no ACEs reported increased from 16.7% to 21.6% over that time-although those reporting 4+ ACEs also increased slightly, from 43.1% to 51.1%. 12

Children in the GUS sample were less likely to have experienced 3+ ACEs, than the USA, New Zealand, Welsh and English studies. 1-4 This may well be due to the difference in age-period examined, where previous studies examined ACEs up to the age of 18, compared with up to the age of eight in GUS, providing less time for children to 'accumulate' ACEs.

Other factors which were associated with having increased odds of having 1+ ACE or 3+ ACEs, respectively, were being male, having a younger mother and living in an urban area. The finding that boys were more likely to experience ACEs is similar to that seen in the previous English retrospective study, 2 but was the opposite of findings from Felitti et al, which found that 18% of women experienced 3+ ACEs, compared with 9% of men. This may be due to the two of the items which were unable to be measured (sexual abuse and emotional abuse), both of which are more likely to be experienced by women. 1 The relationship to age of mother was reflected in previous findings: Bellis reported increased odds of higher numbers of ACEs for children born to mothers aged under 20. 11 The exploration of urban/rural differences in ACE counts appears to be a novel contribution to the literature, with no previous evidence produced on these differences, although living in an urban area is independently associated with higher levels of child abuse, 9 drug abuse 23 and heavy alcohol use 24- all contained within the ACE questions. These models focused on sociodemographic risks for ACEs: future research may wish to explore the explanatory power of factors such as attachment, 25 neurodevelopmental disorders, 26 parenting and parental ACEs. 27 28 Additional research is also needed to find out how many Scottish children experience further ACEs up to age 18 and how this compares to other parts of the world.

Conclusion

Around two-thirds of Scottish 8 year-olds had experienced at least one ACE during their life. While this compares unfavourably to previous ACE studies, measurement differences make it difficult to directly compare-although the ACEs reported in this study are clearly a subset of those reported in most studies. Although a large proportion of children had experienced one ACE, just 10% experienced 3+. ACEs were associated with poverty: children living in the lowest household income quintile had odds around seven times higher of having 1+ ACE than the most affluent children.

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Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study

# data[].attributes.attachment_link.description
Background and objectives Adverse childhood experiences (ACEs) have been associated with a range of poorer health and social outcomes throughout the life course; however, to date they have primarily been conducted retrospectively in adulthood. This paper sets out to determine the prevalence of ACEs at age 8 in a recent prospective birth cohort and examine associations between risk factors in the first year and cumulative ACEs.

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'Resilience - the biology of stress and the science of hope'

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'Resilience - the biology of stress and the science of hope'

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THE BIOLOGY OF STRESS & THE SCIENCE OF HOPE "...AN ENGROSSING STUDY OF HOW ADVERSE CHILDHOOD EXPERIENCES (OR ACES) CAN BE LINKED TO DESTRUCTIVE BEHAVIOR AND MEDICAL DISEASES" -Matt Fagerholm ROGEREBERT.COM THE BIOLOGY OF STRESS & THE SCIENCE OF HOPE

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Nurture, Adverse Childhood Experiences and Trauma informed practice

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Nurture, Adverse Childhood Experiences and Trauma informed practice

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Education Scotland report making links between these approaches

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Trauma informed practice and ACES: Critical perspectives on children's mental health and domestic abuse

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Presentation / Conference: Callaghan J (2018) Trauma informed practice and ACES: Critical perspectives on children's mental health and domestic abuse. Children's wellbeing, safety and relationships: A one day conference , University of Stirling, Iris Murdoch Building, 24.05.2018-24.05.2018. https://listenagain.stir.ac.uk/media/2017/jc133/Jane_-_20180524_163930_35.mp4

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All the ACEs: A Chaotic Concept for Family Policy andDecision-Making?

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All the ACEs: A Chaotic Concept for Family Policy andDecision-Making?

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Edwards, R., Gillies, V. et al.

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Adverse childhood experiences: towards a clear conceptual meaning.

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Adverse childhood experiences: towards a clear conceptual meaning.

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Adverse childhood experiences: towards a clear conceptual meaning. - PubMed - NCBI

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Tackling the attainment gap bypreventing and responding to ACEs

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Tackling the attainment gap bypreventing and responding to ACEs

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Paper to inform thinking on adverse childhood experiences and how to use the Pupil Equity Funding to reduce the attainment gap.

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Introduction

This evidence summary seeks to address the following questions relating to adverse childhood experiences (ACEs) and interventions within the education system:

1. How may ACEs impact young people's educational experiences?

2. How can schools best support young people with ACEs?

3. What kinds of approaches have been effective in creating the conditions for positive educational outcomes?

About the evidence presented below

We drew on a wide range of evidence, including academic research in the fields of social work, healthcare, psychology, early years and education in relevant databases (e.g. ASSIA, ProQuest Public Health, SCIE Social Care Online, Social Services Abstracts) and recommendations from specialist organisations (e.g. CELCIS, Scottish Adverse Childhood Experiences Hub). We searched the academic databases, Google Scholar, search engines and key websites using a broad range of terms including variations on concepts including adverse childhood experiences, child behaviour, early life adversity, educational attainment, mental health, outcomes, wellbeing, and trauma informed approaches.

There is relatively little robust research into what works to support attainment, wellbeing and other educational outcomes for young people with ACEs. In an evidence summary of the role of health and wellbeing interventions in schools for NHS Health Scotland, White (2017) found a lack of research studies, conducted in the UK and Ireland, examining health and wellbeing interventions in a school setting that report educational outcomes. The research that has been conducted tends to focus on what works under particular circumstances, rather than what will reliably work anywhere ( Dyson et al. 2010). Howarth et al. (2016) go further, suggesting that in relation to psychoeducational interventions, "there is a need to pause the development of new interventions and to focus on the systematic evaluation of existing programmes" and to "explicitly identify and address the structural, practical and cultural barriers that may have hampered the development of the UK evidence base to date".

The focus of this review was to identify evidence around ACEs and trauma-informed approaches to education and how ACEs can impact educational outcomes. Although we were unable to identify many studies that specifically identified ACEs as a reason for poor attainment and other educational outcomes, this may be due to the methodological difficulties associated with controlling for a wide range of variables in this context.

In our evaluation of the evidence we found that papers reporting on the impact of interventions tended not to rigorously establish causality between activities to support young people with ACEs and any positive outcomes identified. In some instances claims were made about the degree of confidence that researchers had in this connection, but overall there is a lack of ability to determine that existing programmes and activities based around ACEs and trauma-informed practice definitely do result in positive educational outcomes. However, we found qualitative studies that discussed positive student and teacher perceptions of interventions and evidence to suggest activities are well-regarded and do have an impact on the perceptions of the overall school environment.

Despite the limitations of the evidence presented below, a better understanding of what impact ACEs may have on children's behaviour, social and emotional development, and physical and mental health can help people working with children in an educational context to address challenges appropriately and lead to more positive educational outcomes, regardless of whether or not individual children can be identified as 'having' ACEs.

Accessing resources

We have provided links to the materials referenced in the summary. Some of these materials are published in academic journals and are only available with a subscription through the The Knowledge Network with a NHSScotland OpenAthens username. The Knowledge Network offers accounts to everyone who helps provide health and social care in Scotland in conjunction with the NHS and Scottish Local Authorities, including many in the third and independent sectors. You can register here.

Background

There has been a recent interest in approaches to education that support young people with Adverse Childhood Experiences (ACEs), including trauma informed and attachment approaches. For example, the Welsh Government has recently announced that training to help children who face early childhood trauma is to be offered to all schools in Wales. Teachers will be taught how to support pupils who have adverse experiences such as family breakdown, bereavement or physical, sexual or substance abuse. Public Health Wales worked with Cymru Well Wales, Barnardo's Cymru and the NSPCC will create the training package. ( BBC News 12 March 2018). Web of Science analytics indicate that between 2010 and 2017, references to adverse childhood experiences have increased tenfold at a steady pace, suggesting a significant growth in discourse around the concept.

Scottish context

Concerns around ACEs have been picked up by policymakers across education and social care in Scotland. The University of Glasgow Adverse Childhood Experiences Research Centre suggests that children who suffer difficult early experiences, such as illness, neurodevelopmental problems, neglect or abuse can develop mental health problems that can burden them throughout their lives, holding them back in social development, family life, education, the workplace, and even their physical health. Similarly, Health Scotland argues that when children are exposed to adverse and stressful experiences, it can have long-lasting impact on their ability to think, interact with others and on their learning. Dodds (2017) provides a set of slides giving the context to the 'ACEs journey' in Scotland so far linking to key policy documents.

There is currently an evidence gap in the Scottish context, with a lack of clarity around the prevalence specifically of ACEs among the general population ( Fabiani 2018) and a lack of evidence about the efficacy of interventions, the relationship between ACEs and poverty, and the social justice implications of applying the ACEs lens to individual and social disadvantage.

Scottish Government: Getting It Right For Every Child (GIRFEC)

A key policy or approach relating to ACEs in Scotland is Getting It Right For Every Child (GIRFEC) ( Scottish Government 2018). It connects ACEs like parental drug and alcohol abuse, parental incarceration, physical or sexual abuse or neglect, to poorer physical and mental health in adulthood, risky health behaviours, violence and homelessness.

The document states that the Scottish Government will "embed a focus on preventing ACEs and supporting the resilience of children and adults in overcoming early life adversity across all areas of public service, including education, health, justice and social work". There is a heavy emphasis on prevention of ACEs and mitigation of their impact. Interventions include:

Measures to reduce parental incarceration by moving to a presumption against short sentences

More support for children and families in the very earliest years, through expansion in Health Visitor numbers and roll-out of Family Nurse Partnerships

The expansion of high quality early learning and childcare, including action to increase take-up of provision for 2 year olds

Investment in projects and services which support parents and families to cope better, keep children safe and prevent children going into care

Providing funding direct to schools to tackle the attainment gap

In this document, the Scottish ACEs Hub directly connects ACEs to the school context and argues that tackling ACEs will support educational attainment through improving the mental health and wellbeing of young people through schools' improved understanding of the behavioural outcomes of early adversity and resulting developments around learning to be a supportive and inclusive environment for learning. It emphasises the importance of understanding child development and how early childhood adversity can impact on biology, relationships and the ability to learn.

This review draws together some evidence around effective school-based interventions that have demonstrable impact on outcomes for children with ACEs.

In this set of videos from the Transforming Children's Services Conference in 2016, several speakers provide their perspectives around and insights and lessons from case studies across Scotland. Speakers include John Swinney, Louise Morpeth, Michael Little, Kenneth Ferguson, Ian Miller and John Fyffe.

The origin of ACEs

The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997. Around 17,000 mostly white, middle class college-educated people in Southern California completed surveys about their childhood experiences and current health status and behaviours, and received physical exams ( Centers for Disease Control and Prevention (CDC) 2016). The findings of this research resulted in the development of the 'ACE Pyramid', which represents the conceptual framework for the ACE Study and the study's findings identify a link between childhood experiences, and adult health and wellbeing outcomes:

Defining ACEs and trauma

According to Corcoran and McNulty (2018), adverse childhood experiences are "traumatic events (e.g., sexual abuse, physical abuse, emotional abuse) or chronic stressors (e.g., neglect, parental separation) that are uncontrollable to the child".

The original ACE questionnaire used the following categories and refer to the respondent's first 18 years of life, which fall under the wider categories of abuse, neglect, and household challenges:

Abuse

Emotional abuse: A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.

Physical abuse: A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured.

Sexual abuse: An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you.

Household Challenges

Mother treated violently: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother's boyfriend.

Household substance abuse: A household member was a problem drinker or alcoholic or a household member used street drugs.

Mental illness in household: A household member was depressed or mentally ill or a household member attempted suicide.

Parental separation or divorce: Your parents were ever separated or divorced.

Criminal household member: A household member went to prison.

Neglect (Collected during Wave 2 only)

Emotional neglect: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support (Items were reverse-scored to reflect the framing of the question).

Physical neglect: There was someone to take care of you, protect you, and take you to the doctor if you needed it (items were reverse-scored to reflect the framing of the question), you didn't have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.

A distinction is made between stressful life events and adverse childhood experiences. The former is associated with undesirable life events such as parental divorce or illness of a loved one whist the latter to the experience of more severe very traumatic life events, such as being or seeing someone else physically or sexually abused or being caught in a fire, that can be associated with post traumatic stress disorder ( Parkinson 2012).

However, there are some concerns with the categories selected for ACEs criteria, and authors such as Mersky et al. (2017) suggest the need for a more systematic approach to conceptualising and measuring ACEs. Similarly, there is no consensus on the use of terms associated with trauma in childhood, which makes efforts to both implement and study trauma-informed approaches to care challenging ( Maynard et al. 2017). Some researchers have also challenged the validity of retrospective adult reporting of ACEs ( Hardt and Rutter 2004), which is the method the original studies and many others since have been based on.

Impact of ACEs

The original ACE study ( CDC 2016) found the following:

The ACE score, a total sum of the different categories of ACEs reported by participants, is used to assess cumulative childhood stress. Study findings repeatedly reveal a graded dose-response relationship between ACEs and negative health and well-being outcomes across the life course. As the number of ACEs increases so does the risk for the following:

Alcoholism and alcohol abuse

Chronic obstructive pulmonary disease

Depression

Fetal death

Health-related quality of life

Illicit drug use

Ischemic heart disease

Liver disease

Poor work performance

Financial stress

Risk for intimate partner violence

Multiple sexual partners

Sexually transmitted diseases

Smoking

Suicide attempts

Unintended pregnancies

Early initiation of smoking

Early initiation of sexual activity

Adolescent pregnancy

Risk for sexual violence

Poor academic achievement

The theory behind ACEs is that adverse childhood experiences lead to neurobiological impacts and health risks, which in turn lead to long-term social and health problems. The greater the neurobiological impacts and health risks, the more serious the lifelong consequences to health and wellbeing. ( Kahn and Vezzuto 2015)

Impact of trauma on educational outcomes

In a systematic review of the effects of trauma-informed approaches in schools, Maynard et al. (2017) outline existing evidence of the impact of trauma on educational outcomes:

In a systematic review specifically examining school-related outcomes of traumatic event exposure, Perfect and colleagues (2016) identified 44 studies that examined cognitive functioning, 34 that examined academic functioning and 24 that examined social-emotional-behavioural functioning. Their findings suggest that youth who have experienced trauma are at significant risk for impairments across various cognitive functions, including IQ, memory, attention and language/verbal ability; poorer academic performance and school-related behaviours such as discipline, dropout and attendance; and higher rates of behavioural problems and internalizing symptoms.

Other studies suggest that ACEs increase the risk of behaviour and learning problems in children ( Burke et al. 2011; Freeman 2014; Hunt et al. 2017; Iachini et al. 2016), as well as physical and mental health outcomes in later life ( Crouch et al. 2018).

Limitations and concerns

As discussed above, Mersky et al. (2017) and others have expressed concern about the definition of ACEs and the items identified within the ACEs framework. Coyne (2017) argues that the ACE checklist is "a collection of very diverse and ambiguous items that cannot be presumed to necessarily represent traumatic experiences". He also argues that the methods used to research the impact of interventions are limited, suggesting that "claims about the efficacy of trauma-focused treatment are not borne out in actually examining effects observed in randomized controlled trials".

Other researchers have raised the issue that the impact of ACEs is not necessarily the same across all young people. Although some research suggests that the higher the number of ACEs experienced, the worse the life outcomes, some researchers suggest that this data is not reliable due to evidence to suggest, for example, that young BME people are less likely to report mental health problems than young white people ( Garland et al. 2005). Additionally, girls are more likely to demonstrate mental health problems than boys ( Cauffman et al. 2007). Furthermore, there is a lack of clarity around the specific impacts of specific ACE categories on young people. For example, Murray et al. (2012) found that "[t]he most rigorous studies showed that parental incarceration is associated with higher risk for children's antisocial behavior, but not for mental health problems, drug use, or poor educational performance." This indicates a potential need for a better understanding of what challenges young people with different ACEs are more likely to experience in order to effectively design programmes of support in schools.

Evidence

A significant body of research exists causally connecting adverse childhood experiences to poor educational outcomes. For example, Cook et al (2005) suggest:

By early elementary school, maltreated children are more frequently referred for special education services. A history of maltreatment is associated with lower grades and poorer scores on standardized tests and other indices of academic achievement. Maltreated children have three times the dropout rate of the general population. These findings have been demonstrated across a variety of trauma exposures (eg, physical abuse, sexual abuse, neglect, exposure to domestic violence) and cannot be accounted for by the effects of other psychosocial stressors such as poverty.

Recent doctoral research by McDowell (2017) identified that young people who had multiple ACEs were less likely to care about doing well in school and less likely to do all required homework than children who had no ACEs.

However, a significant amount of research fails to demonstrate that ACEs are the cause of negative educational outcomes and therefore are not able to demonstrate that these experiences are not confounders of an underlying causal element such as poverty. The studies presented below demonstrate a causal link between ACEs and impacts including educational outcomes.

Studies measuring the effectiveness of interventions to mitigate against ACEs

The interventions summarised below include trauma-informed, attachment aware and ACE approaches to interventions to support young people in the school environment and with educational attainment.

This study examines the effectiveness of three community-based trauma treatments with 842 child welfare involved children and young people to assess whether participation in treatment predicted positive child outcomes for the different models. Key findings include that trauma treatment was associated with significant improvements in child behaviour problems, post-traumatic stress symptoms, strengths and needs; results differed by treatment model, with optimal outcomes for children receiving Attachment, Self-Regulation and Competency (ARC) and Trauma-Focused Cognitive Behavioural Therapy (TF-CBT).

This mixed-methods study looks at the impact of an Attachment Aware Schools Programme run by Bath and NE Somerset Council, Bath Spa University and Kate Cairns Associates between October 2015-July 2016. The training included part-time continuing professional development with sessions at Bath Spa University, e-learning, consultant support for planning and evaluation and completing a practical project. Participants in the training were 25 participants from 16 schools (6 secondary, 7 primary, 1 middle and two special schools), who were mainly teachers, with two teaching assistants and two family support workers (with a social work background). In addition to impacts on the recipients of the training, the study aimed to identify any improvement in children's educational progress, well-being, and attendance (including exclusions).

Using surveys, documentary analysis, data analysis, observation and interviews, the researchers found evidence to suggest that the training had an impact on whole staff understanding of attachment, the meaning behind behaviour and emotional well-being.

The authors report that attainment in the schools for the 'vulnerable students' targeted by the scheme increased in the year since the programme ended. However, only six of the ten schools provided attainment data for these students which means the extent of the impact is unclear. Additionally, it is not clear if the change in attainment can be attributed to this specific programme or if these six schools were also investing in other activities that may have supported student attainment, for example. The authors argue that the general attainment data for all the schools in the programme supports a positive trend in increasing attainment. However, due to changes in measuring attainment across the years included in the data, it is not clear whether the schools have seen an increase in attainment, and if this potential impact is due to the Attachment Aware Schools programme. The authors identify several other Programmes running alongside the Attachment Aware Programme, such as Thrive, Place 2B, ELSA and Mindfulness.

Students and teachers reported positive changes to the school environment, student behaviour and student well-being, which were viewed as interconnected. The pre- and post-intervention surveys of teachers from the six out of 16 returned sets of data indicated reductions in emotional problems, conduct problems, hyperactivity and peer problems. Pro-social behaviour scores increased.

Attendance data indicates a reduction in attendance across 10 of the 16 schools. However, the authors suggest some schools also saw reductions in persistent absences. There is also a lack of a clear picture about attendance of looked after children, and the proportion of unauthorised absences within the attendance data.

Despite the limitations of the methodology and analysis of the data available, this report is an example of the potential impact of attachment informed schools in the UK and connects qualitative evidence from participants to quantitative findings which may provide useful insights.

This evaluation aims to: provide an independent assessment of the outcomes of the Attachment Aware Schools Programme in developing knowledge and understanding of the effects of trauma and neglect on attachment and
learning and attitudes towards practices for vulnerable pupils in schools. Findings indicate that the programme contributed to staff understanding of attachment theory and emotion coaching. As with Dingwall and Sebba's report described above, any improvements in educational outcomes and pupil attendance cannot definitely be attributed to the programme under study. However, the report includes feedback from pupils about their perceptions of the school environment following intervention that may be of relevance.

This evidence synthesis focuses on programmes or intervention with the aim of improving behavioural, mental health or social and educational outcomes for children exposed to domestic violence and abuse. The authors state:

The evidence for clinical effectiveness of the studies included in the review was limited, and where an effect was found there were improvements in behavioural or mental health outcomes, with modest effect sizes but significant heterogeneity and high or unclear risk of bias. Psychoeducational group-based interventions delivered to the child were found to be more effective for improving mental health outcomes than other types of intervention. Interventions delivered to (non-abusive) parents and to children were most likely to be effective for improving behavioural outcomes. However, there is a large degree of uncertainty around comparisons, particularly with regard to mental health outcomes...

There is limited evidence for the acceptability of other types of intervention. In terms of the UK evidence base and service delivery landscape, there were no UK-based trials, few qualitative studies and little widespread service evaluation. Most programmes are group-based psychoeducational interventions. However, the funding crisis in the DVA sector is significantly undermining programme delivery.

This article explores the relationship between the extent of childhood adversity, adult health risk behaviors, and principal causes of death in the United States. It provides a selective review of the ACE Study and related social science research to describe how effective social work practice that prevents ACEs and mobilizes resilience and recovery from childhood adversity could support the achievement of national health policy goals.

The authors argue that social work responses to adverse childhood experiences may contribute to improvement in overall health. They outline prevention and intervention response strategies with individuals, families, communities, and the larger society.

Rose, J et al. (2015) Emotion coaching - a strategy for promoting behavioural self-regulation in children/young people in schools: a pilot study. The European Journal of Social and Behavioural Sciences, 13(1), pp.1767-1790(Open Access)

This study explores the effectiveness of using emotion coaching in professional practice within community settings. emotion coaching techniques to promote a more relational and skills-based approach to supporting children's behaviour.

Two year pilot used mixed methods. Participating institutions included 1 secondary, 4 primary schools, 4 children's centres and 1 youth centre for Part 1 of the pilot (year 1) and 1 secondary school and 5 primary schools for Part 2 of the pilot (year 2).

Participants included senior and junior teaching staff, teaching assistants, school support staff, Children's Service staff including health and social care services, early years practitioners, youth workers and youth mentors, and some parents. Participants were trained in emotion coaching techniques (the training phase) and supported via four network/booster meetings (the action research phase) to adopt, adapt and sustain emotion coaching into their practice over a period of one year for each setting pre- and post-impact psychometric questionnaires with all participants, exit questionnaires with all participants, pre- and post- training behaviour indices and oral recordings of the network/booster meetings and focus group discussions.

Findings focus on the emotion coaching in schools and report changes in behavioural and socialisation practices. Quantitative analysis identifies a reduction in the number of call-outs (incidents where children are called out of the classroom), exclusions (external exclusion from school), and consequences (sanction applied), and an increase in rewards for pro-social behaviour. Results indicate a positive impact on professional practice, adult self-regulation and improvements in children/young people's self-regulation and behaviour. The authors suggest that emotion coaching promotes children's self-awareness of their emotions, positive self-regulation of their behaviour and generates nurturing relationships. However, the paper does not indicate that children's perspectives were included in analysis and findings are therefore limited to teachers' self-reporting of their behaviour before and after the training. It is also not clear if the training was the causal factor for the improved quantitative outcome measures.

This report summarizes the final findings of an evaluation of community-based initiatives in Washington State that were intended to prevent child maltreatment and exposure to toxic stress, mitigate their effects, and improve several child and youth development outcomes.

The study focused on outcomes identified by the initiatives that were believed to be successful, and sought to validate sites' perceptions of effectiveness by examining changes in related outcomes with rigorous evaluation methods.

The study found that 6 (of the 11) evaluated activities were associated with positive and statistically significant changes in targeted outcomes. The remaining five activities either had inconsistent findings or had limited or no outcomes data available. Where positive changes were identified, these related to the following outcomes:

Resolving barriers to regular school attendance

Reduction of in-school suspension

Increase of school rewards for pro-social involvement

Decrease in student reporting of low commitment to school

Improvements in reading proficiency in some year groups

Reducing teenage drinking

Reduction in "negative maternal behaviors"

Examples and recommended practice

This section focuses on examples of trauma, attachment and ACEs informed approaches to education and documents that make good practice recommendations.

The quality of school attended is important for young people's health and wellbeing, and schools play a critical role in the development of children and young people's social networks and their experiences of social relationships ( Dodds 2016). Research indicates that the school setting can offer protection against adversities ( McPherson 2013 in Dodds 2016).

The six key principles of a trauma-informed approach include safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural, historical and gender issues ( SAMHSA, 2014 in Maynard et al. 2017). Maynard et al. (2017) emphasise that A trauma-informed approach "can include trauma-specific interventions, but trauma-specific interventions alone are not seen as sufficient for achieving optimal outcomes or to influence service systems".

The ACEs lens can be applied in different ways, including primary prevention and through 'ACE-aware/informed' services. In the context of this review, educational interventions are conceptualised as secondary interventions rather than primary prevention.

Depending on the severity of ACEs they could be conceptualised as traumatic. We have therefore also provided resources relevant to trauma-informed education.

This website has a list of resources including videos and journal articles that may have useful information.

The attachment aware approach is based on the idea that "[e]ducators must establish attachment-like relationships with their students, particularly with challenging and vulnerable children and young people, in order to improve their chances of learning and achieving." The Bath Spa website provides information about how the approach has been used in schools, including its use by teachers dealing with behavioural, academic and truancy issues, case reports.

Key research findings from the project include:

Nurturing adult attachments provide children with protective, safe havens and secure bases from which to explore and engage with others and their environment (Bowlby 1988)

Early care-giving has a long-lasting impact on development, the ability to learn, capacity to regulate emotions and form satisfying relationships (Siegel 2012)

Attachment is crucial to children's psychological welfare and forms the basis of personality development and socialisation (Bowlby 1988)

Teachers, youth workers and significant adults in a child's life can provide important attachments for children (Bergin and Bergin 2009, Riley 2010)

The National Institute for Health and Care Excellence (NICE) 2015 guidelines on children's attachment indicate the importance of attachment issues in schools.

Potentially relevant videos about attachment aware schools include:
Why do we need attachment aware schools? How do we create an attachment aware school? Making a difference through everyday practice
This non-statutory advice clarifies the responsibility of the school, outlines what they can do and how to support a child or young person whose behaviour - whether it is disruptive, withdrawn, anxious, depressed or otherwise - may be related to an unmet mental health need. It includes recommendations for practice including positive classroom management and small group work, social skills development, peer mentoring and support from external bodies.

Forster, M et al. (2017) Associations between adverse childhood experiences, student-teacher relationships, and non-medical use of prescription medications among adolescents. Addictive Behaviors, 68(1), pp.30-34 (Available with NHS Scotland OpenAthens username or author copy)

This study explores whether student-teacher relationships can help prevent the use of nonmedical use of prescription medication by young people with ACEs. Using a survey of 104,332 8th, 9th and 11th grade students in Minnesota in 2013, the research suggests that cultivating strong student-teacher relationships are important considerations for future school-based substance use prevention initiatives. However, this is not based on a causal relationship between student-teacher relationships and drug (non)use. Although there is evidence to suggest that caring bonds with adults support healthy development, the authors acknowledge that there is "scant research investigating whether positive, caring student-teacher relationships have compensatory effects for youth raised in dysfunctional familial environments".

This book offers an introduction to therapies produced as a result of the popularity of attachment studies. These therapies can be divided into two categories: those that are 'attachment-based', in that they use evidence-based attachment assessments in their development, or 'attachment-informed', in that the theories of attachment have been integrated into the practice of existing schools of therapy. The book reviews the field and provides a range of interventions for children, adults and parents.

This presentation provides a clear overview of the types of childhood trauma and the background theory to the recommendations around how educators can create a trauma-informed school with a multi-tiered system of support services.

This background and plan for a systematic review into the impact of trauma-informed approaches in schools includes several excerpts that may be of relevance, including:

A trauma-informed approach in schools is designed to create a systematic model for schools to decrease the impact of trauma on students (Wiest-Stevenson & Lee, 2016) and more appropriately address academic, behavioral and socio-emotional problems by recognizing and responding to student behavior from a trauma-informed perspective. This is done through a multi-level approach intended to improve the school environment through implementing trauma-informed policies and procedures; increase the ability of school staff to recognize and more effectively respond to students through professional development; and prevent, mitigate and reduce trauma-associated symptoms through evidence-informed practices, leading to improved student academic, behavioral, and socio-emotional outcomes.

While schools may be implementing trauma-informed approaches, it is unclear to what extent or how much variation there is in what schools are implementing, how much emphasis they are putting on various components (e.g., workforce development versus organizational change versus practice changes) and whether schools may implement trauma-informed approaches differently based on the characteristics of their students, neighbourhood, country or other contextual factors.

The results of this systematic review have not yet been published, but will be shared on the Campbell Collaboration webpage for the study when they are available.

A limitation of the systematic review is that it does not intend to include qualitative research, which means that impact that cannot be recorded using quantitative measures will not be captured.

This study of 29 students in seventh and eighth grade in the US examined the impact of the RAP Club, sessions led by teachers that incorporate psychoeducation, cognitive behavioral (CBT), and mindfulness strategies to focus on several areas:

Identifying stress

Awareness of emotional states

Using a mindful approach

Communication skills

Problem solving skills

Distress tolerance skills

The research found that the trauma-informed group activity improved teacher-rated emotion regulation, social and academic competence, classroom behavior, and discipline, but that student self-report outcomes did not differ between students who attended the sessions and the control group.

Methodological limitations of this pilot study include small sample size, a volunteer sample, limitations to the randomization process, and no long-term follow-ups. The teachers who rated the children's changed behaviour were also aware of the intervention taking place (but had limited knowledge of what the programme entailed).

This guideline covers the identification, assessment and treatment of attachment difficulties in children and young people up to age 18 who are adopted from care, in special guardianship, looked after by local authorities in foster homes (including kinship foster care), residential settings and other accommodation, or on the edge of care. It aims to address the many emotional and psychological needs of children and young people in these situations, including those resulting from maltreatment.

Recommendations include:

Schools and other education providers should ensure that all staff who may come into contact with children and young people with attachment difficulties receive appropriate training on attachment difficulties

Health and social care provider organisations should train key workers, social care workers, personal advisers and post-adoption support social workers in the care system, as well as workers involved with children and young people on the edge of care, in:

Recognising and assessing attachment difficulties and parenting quality, including parental sensitivity

Recognising and assessing multiple socioeconomic factors (for example, low income, single or teenage parents) that together are associated with an increased risk of attachment difficulties

Recognising and assessing other difficulties, including coexisting mental health problems and the consequences of maltreatment, including trauma

Knowing when and how to refer for evidence-based interventions for attachment difficulties

The guidelines also provide recommendations for attachment-focused interventions and effective methodologies for designing and evaluating the impact of these interventions. Specific recommendations are provided for designing and evaluating interventions in a school setting.

This website discusses the role of schools and strategies for trauma-informed care in schools. It provides examples, including UCSF Healthy Environments and Response to Trauma in Schools (HEARTS) project, which recommends the following strategies for teachers:

1. Recognize that a child is going into survival mode and respond in a kind, compassionate way. When you notice that a child might be having a difficult time, start by asking yourself, "What's happening here?" rather than "What's wrong with this child?" This simple mental switch can help you realize that the student has been triggered into a fear response, which can take many forms.

2. Create calm, predictable transitions. Transitions between activities can easily trigger a student into survival mode. Some teachers will play music, ring a meditation bell or blow a harmonica to signal it's time to transition. The important thing is to build a routine around transitions so that children know: a) what the transition is going to look like, b) what they're supposed to be doing, and c) what's next.

3. Praise publicly and criticize privately. For children who have experienced complex trauma, getting in trouble can sometimes mean either they or a parent will get hit. And for others, "I made a mistake" can mean "I'm entirely unlovable." Hence, teachers need to be particularly sensitive when reprimanding these students.

4. Adapt your classroom's mindfulness practice. Mindfulness is a fabulous tool for counteracting the impact of trauma. However, it can also be threatening for children who have experienced trauma, as the practice may bring up scary and painful emotions and body sensations.

This 1-hour webinar produced by NYSUT looks at the latest research on trauma among school children, exploring trauma's prevalence and impact on childrens' behavior, relationships, and learning. Elements of a trauma sensitive school approach are offered along with resources for implementation.

Findings in this report aim to inform the potential benefits to mental health in Wales of developing resilience both in children and adults to mitigate at least some of the detrimental impacts of experiencing ACEs. It includes recommendations of actions that can be taken to support young people to develop resilience.

This short report provides a potentially useful and clear outline defining trauma, identifying the potential impact of trauma and considering the benefits of multilayered systems of support (MTSS). The authors emphasise the potential benefits of an MTSS approach for all students:

Schools have an opportunity to provide a range of supports to students who experience stress or trauma through an MTSS approach. More specifically, these approaches can help all students feel safe, supported, and connected, including those with undisclosed trauma histories.

This paper has been produced to inform thinking about the impact of adverse childhood experiences and how to use the Pupil Equity Funding to reduce the attainment gap. It highlights key factors that play a role in children achieving their potential.

Steele, H and Steele, M (2018) Handbook of attachment-based interventions. London: Guilford Press

This book examines science-based interventions that have been effective in promoting attachment security. Focuses on strengthening caregiving relationships in early childhood and working with children and parents who have been exposed to trauma and other adverse experiences. Includes interventions for school-age children, at-risk adolescents and couples, with an emphasis on father involvement in parenting. Describes the approaches and how they are informed by attachment theory and research, how sessions are structured and conducted, special techniques used, the empirical evidence base for the approach, and training requirements. Includes illustrative case material. (Summary from NSPCC)

The Trauma and Learning Policy Initiative argues that trauma-sensitive schools help children feel safe to learn. They define the core attributes of a trauma sensitive school to include:

A shared understanding among all staff

The school supports all children to feel safe physically, socially, emotionally, and academically

The school addresses students needs in holistic ways, taking into account their relationships, self-regulation, academic competence, and physical and emotional well-being

The school explicitly connects students to the school community and provides multiple opportunities to practice newly developing skills

The school embraces teamwork and staff share responsibility for all students

Leadership and staff anticipate and adapt to the ever-changing needs of students

The website provides several reports, research outputs and other potentially relevant resources.

This evidence briefing conducted for NHS Health Scotland and Education Scotland examines the effectiveness of health and wellbeing interventions in a school setting to potentially reduce inequalities in educational outcomes.

Several potentially effective types of intervention are identified and the methods of delivery that have been found to work well are highlighted. Key findings include:

Programmes that fit the needs and context of the class or school and are easy to carry out are more likely to be implemented well

The quality of implementation of social and emotional learning programmes was important for positive outcomes

International review-level evidence suggests that universal social and emotional learning programmes can have positive impacts on wellbeing and educational outcomes. However, findings from studies conducted in the UK and Ireland were mixed.

Offering healthy, nutritious lunches at school tended to have beneficial effects on educational outcomes.

There was inconsistent evidence that breakfast clubs, where children were provided with a nutritious breakfast at school, have an impact on educational outcomes.

A number of studies reported beneficial effects such as lower anxiety levels and improved concentration which have been linked to positive learning-related behaviours

However, a limitation of the studies included in the review is that there is a lack of evidence around the effect of interventions on children and young people from different socio-economic or ethnic backgrounds. There is also a general lack of longitudinal research so it is not clear if the effectiveness of the interventions is long-lasting.

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Bath Spa University (no date) Attachment aware schools project (website)

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This evidence summary seeks to address the following questions relating to adverse childhood experiences (ACEs) and interventions within the education system: How may ACEs impact young people's educational experiences? How can schools best support young people with ACEs? What kinds of approaches have been effective in creating the conditions for positive educational outcomes?

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Adverse Childhood Experiences: Beyond Signs of Safety; Reimagining the Organisation and Practice of Social Work with Children and Families

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Adverse Childhood Experiences: Beyond Signs of Safety; Reimagining the Organisation and Practice of Social Work with Children and Families

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Adverse Childhood Experiences: Beyond Signs of Safety; Reimagining the Organisation and Practice of Social Work with Children and Families

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Abstract. While an adverse childhood experience (ACE)-informed approach to child protection and welfare has become influential in USA, it has had markedly less

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Capability and adversity: reframing the “causes of the causes” for mental health

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Capability and adversity: reframing the “causes of the causes” for mental health

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"You must always remember that the sociology, the history, the economics, the graphs, the charts, the regressions all land, with great violence, upon the body." (Coates, 2015)

Introduction

Scotland is a proud small country, sadly burdened with the worst health in Western Europe. Poverty, inequality and the consequences of de-industrialisation have undoubtedly made Scots more sick, but these are not the only reasons. Even after adjusting for these socioeconomic influences, Scotland still experiences an "excess" of about 5000 deaths per year.

Scotland's high mortality is a relatively recent phenomenon, emerging only from the 1950s onwards (McCartney and Walsh et al., 2012), and mainly driven not by the poor diet of urban legend (Morrison and Petticrew, 2004), but instead by poor mental health and wellbeing. Two thirds of the country's excess mortality is caused by high rates of suicide, alcohol and drug abuse and "external causes", including violence (Walsh et al., 2016).

What's going on? Studies of a range of "unconventional" influences on health (including social capital, "sense of coherence", social mobility, climate, and sectarianism) failed to find any significant effects (McCartney and Collins et al., 2012; Walsh et al., 2013). More recent work has set out a complex, composite narrative which relates excess mortality in the West of Scotland to latent effects arising from historical deprivation, harmful social policy, educational under-attainment, the scope and scale of urban change, and measures of deprivation that probably underestimated the "lived reality" for many Scots (Walsh et al., 2016).

This short paper takes the patient untangling of the causes of excess mortality in Scotland as a starting point for a more general exploration of the socio-economic, psychological and political dynamics which influence population health, and especially mental health. It reviews the insights provided by research into Adverse Childhood Experiences, and argues that we need to embed our understanding of the causes of "toxic" stress within a wider frame. Nussbaum's Capability Approach could provide such a frame.

An international context

The Scottish case is well known, but certainly not unique. One of the most dramatic peacetime increases in mortality took place in Russia from 1990-1994, when male life expectancy reduced by 6.1 years nationwide, and by an even higher proportion in cities: in Moscow, life expectancy dropped by 7.7 years (Parsons, 2014). The main causes of death were cardiovascular disease, suicide, violence, and alcohol-related deaths. Younger adults were particularly prone to mortality from violence and suicide (Shkolnikov et al., 2001).

Journalist Masha Gessen described the impact amongst her own contacts and acquaintances:

"The deaths kept piling up. People-men and women-were falling, or perhaps jumping, off trains and out of windows; asphyxiating in country houses with faulty wood stoves or in apartments with jammed front-door locks; getting hit by cars that sped through quiet courtyards or plowed down groups of people on a sidewalk; drowning as a result of diving drunk into a lake or ignoring sea-storm warnings or for no apparent reason; poisoning themselves with too much alcohol, counterfeit alcohol, alcohol substitutes, or drugs; and, finally, dropping dead at absurdly early ages from heart attacks and strokes." (Gessen, 2014)

A similar profile began to emerge in the United States from the late 1990s. Between 1999 and 2013, mortality rates of middle-aged white men and women increased (Case and Deaton, 2015), especially in poorer communities affected by economic decline (Meit et al., 2017). The increased mortality was principally caused by drug and alcohol poisonings, suicide, and alcohol-related liver disease, accompanied by declines in overall health and particularly in mental health.

The financial crisis in Greece also led to a rise in suicides and mental health problems, though with a reduction in alcohol use (Laliotis et al., 2016). Premature mortality from substance misuse and suicide is also high in indigenous communities around the world, reflecting current and historical trauma, discrimination and disempowerment (Hunter and Harvey, 2002; Evans-Campbell, 2008; Wilk et al., 2017).

Economic and social dislocation does not always lead to increased mortality (in countries like Iceland, health improved after the financial crash). Where positive effects occur, they seem to be in response to assertive mitigating action by government (Stuckler et al., 2009).

While each situation has its own characteristics, there is typically a pattern of premature mortality strongly influenced by drug and alcohol misuse and suicide. Ethnologist Michelle Parsons borrowed the Muscovite phrase ne nuzhny ("dying unneeded") to understand the Russian mortality crisis (Parsons, 2014). Case and Deaton evoke a similar sentiment by describing the causes of increased mortality in the US as "diseases of despair" (Case and Deaton, 2017). The terms may have journalistic rather than scientific origins, but nonetheless we might reasonably ask why being "needed" should be so important, and how "despair" could affect health so dramatically. A growing body of evidence relating to the adult consequences of childhood adversity may offer some clues.

Can ACEs help us understand these effects?

In 1998, Vincent Felitti and colleagues published a landmark paper about the influence of Adverse Childhood Experiences (ACEs) on health in adulthood (Felitti et al., 1998). ACEs were defined as ten forms of adversity experienced before the age of 18 years. They include exposure to physical, sexual and emotional abuse; physical and emotional neglect; and five kinds of "household dysfunction" (parents separated or divorced, domestic violence, substance misuse, mental illness and incarceration in prison). An "ACE score" is simply the count of these individual adverse experiences.

The study found not only that ACEs were common (two thirds of their sample had experienced at least one adversity), but also that the impact of ACEs on health and social outcomes in later life was immense. For example, smoking a pack of cigarettes per day will reduce life expectancy by about 10 years (Jha et al., 2013); but having an ACE score of six or more will reduce life expectancy by 20 years (Felitti and Anda, 2014).

The findings of the original ACE study have been replicated many times, and a recent meta-analysis showed that individuals with four or more ACEs were at increased risk of each one of the 23 adverse health outcomes identified (Hughes et al., 2017).

ACEs have a much stronger influence on some outcomes than others. While physical inactivity, overweight and diabetes are only modestly associated with ACE scores, the prevalence of smoking, heavy alcohol use, cancer, heart disease and respiratory disease is moderately increased (two to three times more likely). There is a strong link between mental ill-health and alcohol use, but the strongest associations are evident for problematic drug use, interpersonal violence and self-harm. For example, for people with an ACE score of four or more compared to those with a score of zero, the odds of becoming overweight increase by 39%, and the odds of having cardiovascular disease more than double. But the risk of depression increases more than four times, the risk of being a perpetrator of violence increases eight times, the risk of problematic drug use increases more than ten times, and the risk of making a suicide attempt is more than 30 times higher. High ACE scores therefore seem to be associated with a profile of morbidity similar to that of the "diseases of despair", and the pattern of excess mortality seen in Scotland.

It is generally accepted that ACEs exert their effects through the impact of "major unrelieved stress over prolonged periods of time" (Felitti and Anda, 2014). The phrase "toxic stress" was coined to describe "what happens when children experience severe, prolonged adversity without adult support"(National Scientific Council on the Developing Child, 2014), and the impact of long-term stress on a range of body systems (including immune and endocrine responses, epigenetics, and brain development) is well-characterised (Shonkoff and Garner, 2012; McEwen, 2017). Research has confirmed that the risks associated with ACEs can be mitigated by the presence of a trusted adult being available throughout childhood (Bellis et al., 2017).

The science of ACEs therefore seem to explain at least part of the increased risk associated with socio-economic disadvantage, and a model has been proposed which links conventional socio-economic factors, toxic stress, attachment experience and ACEs with excess mortality (Smith et al. 2016).

But ACEs also have their limitations. Deliberately limited to household effects, ACEs exclude important factors taking place outside the home, such as bullying (Lereya et al., 2015) and racial discrimination (Slack et al., 2016). Researchers have therefore proposed amending the original ten measures to include a range of other harmful exposures, such as racism, witnessing community violence, living in an unsafe neighbourhood, bullying, a history of foster care, parental death, food scarcity, parents always arguing, peer rejection, low socioeconomic status, poor academic performance and having no good friends (Finkelhor et al., 2013; Wade et al., 2016). Extending the scope of ACEs in this way seems to provide a more accurate representation of the prevalence of adversity, especially for people living in deprived and ethnically diverse areas (Cronholm et al., 2015).

In summary, the original ACE study related childhood adversity to poor outcomes in adulthood. Chronic stress mediates those effects over the lifespan, modified by attachment processes in the form of protective relationships with adult carers. Since many poor health outcomes for parents are simultaneously new ACEs for their children, the potential for inter-generational transmission of adversity becomes apparent. Extending the scope of ACEs to include discrimination, exposure to community violence and poverty evokes a complex ecosystem of influences and interdependencies. It seems likely that different kinds of adverse experiences will have different effects, which themselves will be influenced by critical periods for child development, and the impact of protective or mitigating factors (Bush et al., 2016; McLaughlin and Sheridan, 2016).

There is also a more fundamental issue: both the core and extended versions of ACEs are based on harm caused by toxic stress, elicited in various forms across the life course. ACEs represent a deficit model, but what would a normal (or optimal) life course look like? Nussbaum and Sen's "Capabilities Approach" provides a practical insight (Nussbaum, 2011).

Capabilities

The "capabilities approach" was developed as a paradigm for improving social justice in policy-making by the economist Amartya Sen and the philosopher Martha Nussbaum (Sen, 1999; Nussbaum, 2011). The approach informed the creation of the United Nation's Human Development Index (United Nations Development Programme, 2017), and has been applied to a range of settings including education, equality, employment, economic development and policy development. In this understanding, people have "functionings" which give their lives meaning and value. Those functionings are underpinned by "capabilities", the freedom or opportunities to achieve those functionings. Capabilities focus on what people are able to do and be, without forming judgements about what they actually do in practice.

Nussbaum proposes a set of ten core human "capabilities" which are necessary to live well (Fig. 1). Wellbeing is assessed by the extent to which someone might be able to realise their capabilities in each domain. These capabilities considered as inherently valuable, rather than being simply a means to other objectives. Since it considers ends as well as means, Capabilities recognises that people may vary in their ability to use their resources to achieve their objectives. "Conversion factors" at personal, social and structural levels influence peoples' ability to achieve socially just outcomes (Brunner and Watson, 2015). While focussing on outcomes, Capabilities recognises that resources matter to their achievement; poverty therefore represents a kind of "capability-deprivation" (Sen, 1999).

Fig. 1

Nussbaum's ten capabilities (abridged from Nussbaum, 2011 pp 33-34)

Childhood adversity clearly has the potential to limit functional capabilities. Nine of the original ten ACE items would disrupt one or more capabilities (with the exception of experiencing parental separation). Childhood abuse and neglect, for example, would harm the capabilities in respect of "bodily health and bodily integrity". Living with someone with mental illness or substance misuse problems might impair "attachment to persons outside ourselves" in the 'emotions category'. The extended list of ACEs is also consistent with capabilities: "poor academic performance" relates to the "senses, imagination and thought domain", and experiencing community violence and discrimination would limit "control over one's environment".

High ACE scores are strongly correlated with an increased risk of suicidal behaviour. Models of suicidal causation emphasise factors such as "thwarted belongingness", defeat, humiliation and entrapment (O'Connor and Nock, 2014), and again these influences would find a place in the capabilities approach, relating as they do to "bodily health, affiliation and control over one's environment".

Similarly, "diseases of despair" are not only about the material consequences of unemployment and poverty (which influence bodily health and control over one's environment), but also the psychological harm caused by the frustration and isolation of political disempowerment (affiliation).

Conclusion

The emergence of "excess" mortality in Scotland prompted a systematic research effort to identify causes of illness that were not fully captured by conventional socio-economic models. Excess mortality in other societies at different times suggests that a profile of suicide, substance misuse and violence is often manifest during periods of economic and political dislocation and disempowerment. Since a similar profile is highly correlated with exposure to adverse childhood experiences, one might hypothesise that toxic stress might underly "diseases of despair", just as it does childhood adversity.

If "toxic" stress is so harmful, what might a life free of such stress look like? To ask the question is not to imagine some other-worldly utopia, but instead to seek to better understand the conditions in which human potential and happiness can best be realised.

There is more to this swirling ecosystem of material, political and social influences on health than a list of ten capabilities and ten childhood adversities. Yet such a reframing may offer new insights into potential change: as Lewin argued, "there's nothing so practical as a good theory" (Lewin, 1943).

To incorporate ACEs within the capabilities approach usefully frames adversity in a wider social, philosophical and economic context. To do so is not to underestimate the importance of poverty and inequality as drivers of poor health. In fact, it highlights that such socioeconomic factors are not just a cause of disempowerment, but may be themselves a consequence of it. Adversities and capabilities each operate at the level of individuals, households and societies. The capabilities approach emphasises opportunities, as well as impairments, and the influence of communities, as well as individual circumstances. It is respectful of personal choices and priorities, and usefully extends the scope of "adversity" to consider the harm done when educational and political choices are constrained. "Participative, deliberative and democratic," Capabilities generates a key role for public services to design and apply Conversion Factors:

"the ability to (re)configure services, campaigns, laws, regulations, resources etc. to intervene and achieve a positive and sustainable change in what people experiencing social injustice are actually able to do and be (evidence-informed policy choices), including through co-production or developing assets, and with third sector or private sector partners as required" (Brunner and Watson, 2015)

Childhood adversity and toxic stress are among the underlying causes of many public health problems. Capabilities conceptualises that "toxicity" in a way that might let us recognise and understand it more readily; and in particular to use conversion factors to enable change. These insights are not new in themselves: they are consistent with the priorities of social psychiatry and the recovery movement in mental health, and reinforce the need to tackle inequality, discrimination and educational and political exclusion. ACEs thinking reframes our thinking by asking not "what's wrong with you?" but "what happened to you?" In a similar way, Capabilities links the personal to the structural, and challenges us to change the policy stance and service paradigm from "here's your support" to the more respectful question "what do you need?"

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References

Felitti V, Anda R, Nordenberg D (1998) 'Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. Am J Prev Med14(4):245-258. http://scholar.google.com/scholar?hl=en&btnG=Searchq=intitle:Relationship+of+Childhood+Abuse+and+Household+Dysfunction+to+Many+of+the+Leading+Causes+of+Death+in+Adults:+The+Adverse+Childhood+Experiences+(ACE)+Study#3. Accessed: 26 Feb 2013

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Correspondence to Michael Smith.

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DOI
https://doi.org/10.1057/s41599-018-0066-z

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Capability and adversity: reframing the "causes of the causes" for mental health

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"You must always remember that the sociology, the history, the economics, the graphs, the charts, the regressions all land, with great violence, upon the body." (Coates, 2015) Scotland is a proud small country, sadly burdened with the worst health in Western Europe.

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Screening for adverse childhood experiences (ACEs): Cautions andsuggestions

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Screening for adverse childhood experiences (ACEs): Cautions andsuggestions

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A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years

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A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years

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Social Policy and Society

Adverse childhood experiences (ACEs) have emerged as a major research theme. They make reference to an array of potentially harmful exposures occurring from birth to eighteen years of age and may be involved in the construction of health inequalities over the lifecourse. As with many simplified concepts, ACEs present limitations. They include diverse types of exposures, are often considered cumulatively, can be identified using prospective and retrospective approaches, and their multidimensional nature may lead to greater measurement error. From a public health perspective, ACEs are useful for describing the need to act upon complex social environments to prevent health inequalities at a population level. As the ACEs concept becomes popular in the context of policy interventions, concerns have emerged. As a probabilistic and population-level tool, it is not adapted to diagnose individual-level vulnerabilities, an approach which could ultimately exacerbate inequalities. Here, we present a critique of the ACEs framework, discussing its strengths and limits.

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A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses | Social Policy and Society | Cambridge Core

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Social Policy and Society Adverse childhood experiences (ACEs) have emerged as a major research theme. They make reference to an array of potentially harmful exposures occurring from birth to eighteen years of age and may be involved in the construction of health inequalities over the lifecourse. As with many simplified concepts, ACEs present limitations.

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A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses

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A Critique of the Adverse Childhood Experiences Framework in Epidemiology and Public Health: Uses and Misuses

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Adverse Childhood Experiences (ACEs) are traumatic events that children can be exposed to while growing up. These include the direct impact of suffering abuse or neglect, or the indirect effects of living in a household affected by domestic violence, substance misuse or mental illness. The original ACEs study found that those with a higher number of ACEs were more likely to have physical and mental health difficulties and to engage in health-related risk-taking behaviours than those with less traumatic childhoods. In the 20 years since the study was published the 'ACEs movement' has steadily expanded, particularly in the United States.

It took much longer for the first UK ACEs study to be published and it is only really in the last few years that awareness of ACEs has grown on these shores. England is currently lagging behind Wales and Scotland in recognising ACEs in national policy, though many local areas are developing their own ACEs strategies.

I only heard about ACEs two or three years ago. I was aware of each of the individual experiences that the authors had termed ACEs, but not of their being grouped together and counted. There was something about the idea that nagged away at me right from the start, but I couldn't articulate it. Then I came across a concrete example of good intentions causing harm in a charity I was working alongside. The organisation helps vulnerable people with a range of problems, from domestic violence to involvement with the criminal justice system. Staff had received training on 'ACE-awareness' and how to incorporate routine enquiry about ACEs into their work with service users, apparently to offer more tailored support. Many of the staff had faced the same issues as those they were now trying to help, and several reported finding the training distressing. They were told of the potential damage ACEs can cause, which caused them to worry about the impact it had had on themselves. Several reported feeling guilty about having 'passed on' their own ACEs to their children. They were taught all about the (potential) negative impacts of ACEs, but offered no reassurance that you can have a high number of ACEs and still be totally fine. I posted this issue in an online ACES forum and found that it was not an uncommon issue. I've since worked on various ACEs projects and think my thoughts are finally just about lined up enough to write down.

There are of course lots of examples of fine work going on around ACEs, but there are also aspects of the ACE movement that make me feel a little uncomfortable. I worry that what is clearly a well-intentioned desire to just do something might not do good and could cause harm. My concerns below are absolutely not meant as a criticism of the motivation and altruism underlying the ACEs movement, but as a cautionary nudge to make sure that, in our enthusiasm to do good, we don't run before we can walk.
A narrow definition of adversity
The original ACEs study defined ten kinds of adverse experience; five that involved direct harm to a child (physical, sexual and emotional abuse; physical and emotional neglect) and five that affect the environment in which they grow up (domestic violence; substance abuse; mental illness; parental separation; incarceration of a household member). My first thought on reading the paper was - why just these? What about bullying? Hunger? Homelessness? The death of a parent? And why only things that happen within the household, surely community violence is an adverse experience? Since the initial study, a great many others have been published that include one or more of these or other 'extra' ACEs. To me this illustrates that, outside of academic research, a focus solely on the ten 'official' ACEs was always too narrow.

The ACE movement also seems to conflate adversity with trauma, and the two are very different. In this article, Gary Walsh states that

the term risks suggesting that adversity of any kind is bad or traumatic. While abuse and neglect should always be considered fundamentally wrong, traumatic and preventable, the same cannot always be said for adversity. Everyone will experience adversity at some point and there is often strength and hope to be found in it. Our responses to adversity can nurture resilience and loving relationships while also defining our identities
ACE-awareness
In a way, I think the ACEs movement has become a victim of its own success. It's in danger of becoming its own distinct field, rather than what I think it should have been: another, powerful piece of evidence to raise awareness of and advocate for what we already knew to be important. It has done that to some extent, of course, but unfortunately it has spawned a distinct campaign that has raised awareness primarily of the ten, narrowly-defined ACEs chosen by the original researchers. The ACEs study provided some excellent population-level data, but I don't believe it was ground-breaking research. I know to some that might seem blasphemous, but it will not have come as a surprise to anyone that traumatic experiences occurring early in a child's life can have a lasting impact.

Being 'ACE-aware' has become somewhat of a badge of honour. We now have ACE-aware schools, councils, businesses, even an ACE-aware nation. But awareness without action achieves nothing. There is a world of difference between ACE-awareness and trauma-informed practice. The former can mean different things to different people but may mean as little as having heard of ACEs and that they can be harmful. That's great, but useless on its own. I'm aware of heart surgery, but that doesn't qualify me to advise a triple bypass. There are of course many examples of people or organisations who rightly see becoming ACE-aware as just one piece of the jigsaw that is effective and comprehensive trauma-informed practice, but plenty of others who believe ACE-awareness is an end in itself; and that can be dangerous, as my earlier example demonstrates.
Medicalisation
There is a great deal of published literature asserting that ACEs can have tangible effects on the biology of individuals. This is powerful stuff and has really helped to raise awareness of ACEs because, rightly or wrongly (well, wrongly), issues are often only taken seriously if they can be labelled as a medical problem or considered a disease. The ACEs movement in the States was, initially at least, led by medics, and that is probably one of the reasons it gained traction.

But... if you think about it, why does it matter if ACEs have demonstrable biological effects? Why does that make the case more powerful? In their submission to the House of Commons Science and Technology Select Committee Inquiry into the evidence-base for early years intervention, Edwards et al. asked what I thought was a really pertinent question:

Would a life lived in the miserable conditions created by adverse situations be wrong even if there were no long-lasting biological effects?

Of course it would. So, while the evidence demonstrating that ACEs have a biological impact has been important in raising awareness, there is a danger that ACEs become yet another example of what is essentially a social issue with societal solutions being labelled as a medical one. When that happens, the focus shifts to identifying and 'treating' individuals, rather than prevention at the population level.
Individualism
Time and time again we see the approach to tackling complex social problems focus on searching for 'solutions' at an individual level. What that means is that rather than making the necessary but difficult changes to society that would reduce the risk of rubbish stuff happening , we wait for the rubbish stuff to happen then try to mitigate its effect - what Geoffrey Rose called "a targeted rescue operation for vulnerable individuals". For ACEs, that means that the approach has tended to rely on finding individuals with a high 'ACE score' and then trying to help them (a bit more on the ACE score and that assumption of needing help later). It's a natural and intuitive approach to medicine, but we also know from Rose that, on its own, it has little effect at the population level. For pretty much any disease or negative outcome you can think of, the greatest burden will fall on the vast majority of people considered as low-risk, simply because of their greater numbers:

If we want to prevent ACEs and their consequences at a large scale, then a population approach where we shift the level of risk in the entire population is required. For that we need to prevent the causes of ACEs, and not only act on those individuals already affected. Really, of course, we need to both offer targeted help to those that need it and reduce the level of risk in the whole population (Rose called these the 'high risk' and 'population' strategies, respectively). But we're all skint because of funding cuts, and we can't do both. We're forced to choose between helping those in most pressing need or incrementally improving population health. In that situation, the former always wins. But what a shame we're forced to choose.
ACE scores, screening and 'routine enquiry'
The ACE score (i.e. the number of ACEs an individual has experienced) was designed for population-level epidemiological research. It was not intended to inform practice at the individual level. In their final report, the Science and Technology Committee explicitly state that "the simplicity of [the ACEs] framework and the non-deterministic impact of ACEs mean that it should not be used to guide the support oﬀered to specific individuals."

Demonstrating an association (note association, not cause) between high numbers of ACEs and poor outcomes at the population level tells us precisely nothing about any individual with a high ACE score. It is absolutely possible to have ten ACEs and be totally fine, or to have no ACEs and be a gibbering wreck (I'm proof of that). It is the very definition of an ecological fallacy, yet many advocate its use as a screening tool.

A short while ago I attended a meeting for an organisation who were conducting some research into the experiences of young people involved with the youth justice service. When they passed around the questionnaire they'd been using, I was shocked to see they were asking questions about ACEs. To children. When I asked why they were asking them, they were unsure. They had no plan for what to do with the information and hadn't thought about whether it might be upsetting. The questionnaire was being administered by an 18 year old girl with no training. Luckily, following advice from myself and others, they removed these questions.

There was absolutely no malice in what they were doing of course, they were acting with the best intentions and, well, being ACE-aware I suppose. But any form of screening has the potential to do more harm than good and we " shouldn't let good intentions undermine [...] screening principles". Screening for ACEs risks labelling individuals who are otherwise content and well and basically fine, or signposting them to services they don't need. Or, perhaps worse, highlighting issues that need urgently addressing, but not knowing how to. This paper by David Finkelhor cautions against prematurely screening for ACEs and is a must-read. He states that we don't yet have any evidence-based interventions for high ACE scores and we don't understand the potential negative outcomes and costs of screening:

if general ACE screening were to result in a big increase in unnecessary and inherently expensive child welfare referrals and investigations as one of its main outcomes, we might look back on the ACE mobilization as a disastrous distraction to the development of evidence based child welfare policy

I've also come across advocates for 'Routine Enquiry for Adversity in Childhood'. "It's not screening!", they say. It is screening. There is no evidence it has a positive effect on outcomes. When I've raised this I've been pointed to evaluations like this as evidence. In fact, this one states that:

None of the sites successfully implemented the REACh program

"One of the underlying assumptions [...] is that the enquiry process itself may be therapeutic" but that "practitioners raised concerns that this may not be the case"

"Concerns were expressed around the ethics of identifying ACEs without the ability to offer appropriate support to those who may need it"

"Little evidence currently exists on the value of routine enquiry about childhood adversity, using the ACE (or equivalent) questionnaire, or the responses or interventions required for those reporting childhood adversities"

So not really evidence of effectiveness, then... and yet it's been rolled out across several services in England, including the charity I spoke of in my example earlier.
ACEs as a cause
There is no doubt a strong correlation between ACEs and negative outcomes in no longer life, but that does not necessarily demonstrate causation (see Correlation and causation in the Committee report). I think of ACEs as a symptom of an underlying cause: shit life syndrome, basically. I think this is illustrated really well by the Building Community Resilience (BCR) ' pair of ACEs ' framework:

The Pair of ACEs Tree demonstrates the interconnectedness of wider social circumstances and adverse experiences within the family environment. The leaves on the tree represent the 'symptoms' that are easily recognized in clinical, educational and social service settings, but the underlying causes are the usual suspects: a lack of affordable and safe housing, community violence, inequality, discrimination, poverty, etc..

If generally difficult lives (or ' adverse socioeconomic circumstances ') are the root cause of ACEs, then I'm not sure we even need distinct ACEs prevention strategies; it's the same as preventing everything else. What we need is the funding and freedom to develop broad prevention approaches that focus upstream. A living wage. Clean streets. Good, affordable housing. Parks. Stuff for teenagers to do. Welfare. Jobs. Childcare. Good schools. Of course, we could never prevent everything, so we will always need access to excellent individual support. But that is not going to reduce the incidence of ACEs. Trauma-informed practice and proper help for individuals is absolutely essential, but it's not really prevention is it? We need to tackle the roots of the problem too.
Summary
I've banged on for ages here, so I want to just reiterate that I know there are many hundreds of people and organisations doing excellent, holistic work on ACEs, and that much of what I've written will not be new or relevant to them.

But I have witnessed practices being adopted that aren't (at least yet) based on evidence, but rather the very human desire to just 'do something' to alleviate a perceived injustice. Public health is an evidence-based discipline, but we are all human. We will at times be guilty of picking evidence to suit our own narrative, even unconsciously and with the best intentions. If something seems important, we may choose to do it quickly rather than do it properly. It's not just ACEs of course: Making Every Contact Count, social prescribing, apps... all being rolled out without robust evidence, all ignoring the underlying, upstream factors to a greater or lesser extent. It's something we need to be a little wary of more generally and be careful not to run before we can walk. ACEs are no doubt an important advocacy tool that reflect deeper, underlying problems; but we must not lose sight of the bigger context and wider determinants of public health issues.
Other (better) critiques of ACEs
Much cleverer people have written much more eloquently than me about these issues. I've found those below useful - all very worth a read.

Edwards et al. (2017). The problem with 'ACEs': EY10039: Submission to the House of Commons Science and Technology Select Committee Inquiry into the evidence-base for early years intervention. A very robust criticism of the ACEs approach, which garnered strong support in response from a number of other academics similarly concerned about the limitations of the ACEs approach.

Finkelhor (2017). Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abuse and Neglect.

Taylor-Robinson et al. (2018). Adverse childhood experiences or adverse childhood socioeconomic conditions? The Lancet Public Health.

The Times Educational Supplement has published several articles arguing for and against the ACEs movement:
Zeedyk (2018). Childhood trauma: Why I celebrate the ACE-aware movement's impact.

Walsh (2018). The ACEs campaign: cause for worry or celebration?

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Good intentions but the right approach? The case of ACEs - Public healthy

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Adverse Childhood Experiences (ACEs) are traumatic events that children can be exposed to while growing up. These include the direct impact of suffering abuse or neglect, or the indirect effects of living in a household affected by domestic violence, substance misuse or mental illness.

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Children's Commissioner for Wales

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Adverse childhood experiences or adverse childhood socioeconomic conditions?

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Adverse childhood experiences or adverse childhood socioeconomic conditions?

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Our second guest blog about the links between poverty and Adverse Childhood Experiences (ACEs) is by Dr Morag Treanor, Senior Lecturer in Sociology, Social Policy and Criminology at Stirling University.

Poverty is a structural problem with a lack of income at its core. Poverty is dynamic - those people living in poverty this year are not necessarily the same group of people who will be living in poverty next year. The drivers of poverty in Scotland comprise a wide range of structural, household and individual-level factors including:

macro-economic and political conditions

the housing and labour markets

the cost of living

social security system,

education and skills.

In-work poverty is an increasing problem in Scotland as two thirds of children living in poverty live in a family where at least one adult works. For some people poverty is fleeting and transient, for others it can be severe and persistent. Many children living in poverty will not go on to live in poverty in adulthood; the intergenerational transmission of poverty is not automatic. However, for others, there is a risk of poverty following them into adulthood and blighting their futures.

Adverse Childhood Experiences (ACEs) are stressful events that occur in childhood which can a have lifelong impact on health and behaviour. ACEs include:

domestic violence

parental abandonment through separation or divorce

a parent with a mental health condition

being the victim of abuse (physical, sexual and/or emotional)

being the victim of neglect (physical and emotional)

having a member of the household in prison

growing up in a household in which there are adults experiencing alcohol and drug use problems.

Those who experience multiple ACEs (four or more) in childhood are more likely to have poor physical and mental health (including type 2 diabetes and heart disease) and to engage is health-harming behaviours such drinking, smoking or taking drugs. They are less likely to be able to acquire the confidence and self-efficacy required in adulthood to engage in education or employment. They are more likely to experience severe poverty and destitution, to use food banks, and to experience homelessness. Research has found that having a relationship with one trusted adult during childhood can mitigate the negative impacts of ACEs and that when mothers have a high level of social connectedness child wellbeing increases, even for those living in persistent poverty.

Poverty is not another ACE

At this juncture it is important to note two things: (1) poverty is not another ACE. Often poverty is described as another adverse childhood experience, whereas poverty is a structural issue governed mainly by political and economic factors. It is important for policy and practice not to conflate the two; and (2) although people living in poverty and in the most deprived areas are at greater risk, ACEs do occur across the socioeconomic spectrum. Better-off families often have sufficient material resources and social, emotional or practical support to counter the negative effects of ACEs. This is another reason why poverty should not be confused with ACEs.

With that in mind, while the majority of children living in poverty are not affected by multiple ACEs there is a significant proportion of families with multiple ACEs who experience poverty. And when poverty and ACEs coincide they become more than the sum of their parts. When a child lives with ACEs, and also lives in poverty, the conditions are ripe for long-lasting trauma, or toxic stress, which is devastating to children in childhood, and which continues on into adulthood. The trauma associated with the combination of ACEs and poverty makes it more likely for children to experience deeper and more prolonged levels of poverty throughout their lives and on into future generations.

Families living in poverty affected by ACEs are more likely to come to the attention of schools, statutory and voluntary services as they are unlikely to have the resources, confidence, skills, knowledge, experiences, or the social, emotional or practical support to mitigate the traumatic effects of ACEs. When poverty and ACEs combine children and their families require dedicated service intervention and engagement with multiple services including health, housing, financial and family support workers.

The multi-agency support that these children and families need can be housed where all parents go, for example schools and health services. There is a growing number of money advice workers operating in schools and other hubs, which is highly valuable and which will continue to increase with the boosted funding available under the Child Poverty (Scotland) Act 2017. This will help to alleviate child poverty in Scotland. However, families affected by poverty and multiple ACEs are not likely to be able to benefit fully from poverty-reduction policies due to wider trauma and greater need in their lives.

A holistic view

We need to look at all the pieces on the chessboard and not just focus on each piece in isolation. We cannot improve the lives of all children in Scotland without also addressing the needs of their families. What is required are money advice workers who are also family support workers, or who are trained to recognise the need for, and signpost onto, family support workers. Children 1st operate one such model called the 'Edinburgh Family Support Team' which now delivers integrated benefit, debt and money advice within the wider framework of its trauma-informed family support service for families.

The EFST service has been highly successful in supporting families with evictions, homelessness, disability benefits, sanctions, sequestrations, mental health debt write-offs, bankruptcies and accessing emergency funds. It believes its success is in part due to the fact that its money advice worker is also a trained family support worker and skilled in dealing with family trauma. Such integrated support is valuable because although adverse childhood experiences and poverty do not necessarily coincide, when they do, the resulting trauma can lead to the most intractable and enduring experiences of poverty.

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Poverty and Adverse Childhood Experiences (ACEs)

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Poverty is a structural problem with a lack of income at its core. Poverty is dynamic - those people living in poverty this year are not necessarily the same group of people who will be living in poverty next year.

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19/01 Improving health and wellbeing for people who are at risk of or exposed to Adverse Childhood Experiences (ACEs)

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The Public Health Research Programme are accepting stage 1 applications to their commissioned workstream for this topic.

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The evidence base for routine enquiry into adverse childhood experiences: A scoping review. - PubMed - NCBI