ADVERSE CHILD EXPERIENCES

It was something of a revelation for many of us in medical and social care professions to be introduced to ACEs. A colleague of mine who used to manage the Children’s Intensive Care Unit at Bristol Children’s Hospital has only just recently come across the research. Like many others in associated professions, we recognised that the common factor in almost all the lives of the children and families we engage with is quite simply stress of one kind or another.  

I researched ACEs to satisfy the requirements of continued professional registration with Social Work England as well as to build on the theories, practice and understanding that helps inform our approach in PROMISEworks  This has involved studying the work of Doctors Anda, Felitti and Burke Harris and their research in the field of Adverse Childhood Experiences (ACEs). Anda and Felitti first examined these in 1995 but their work remained relatively unknown until Dr Nadine Burke Harris revisited their findings just a few years ago. Her account is published in a book entitled The Deepest Well. Healing the Long-Term Effects of Childhood Adversity, published in 2018.

In the original study, ACEs referred to three specific kinds of adversity faced by children in their home environments. These were physical and emotional abuse, neglect and household dysfunction. There is a strong and persistent correlation between the number of ACEs experienced and the chance of poor outcomes later in life. These include serious physical and chronic illnesses such as heart disease, diabetes and other chronic conditions as well as depression, anxiety and a range of mental health difficulties. Influences on lifestyle and behaviour include poor academic achievement, substance abuse, unemployment and early death. It seems the overwhelming influence of ACEs is on our stress response through the autonomic nervous system with consequences for our biology and behaviour. ACEs get under the skin and trigger toxic stress and poor outcomes. It is important to recognise that these include social outcomes.

It is now acknowledged that ACEs include many other difficult experiences beyond abuse and neglect and include issues such as divorce, bereavement and domestic violence.

According to Burke Harris, many people who have experienced ACEs are grappling with their lifelong effects but don’t know what they are dealing with. No one has ever told them there might be a problem with their stress response system and that may be related to their ADHD, asthma, diabetes or behavioural and psychological responses to stressful circumstances.

Burke Harris emphasises that excessive activation of stress response systems can damage a child’s developing brain as well as the immune system, metabolic regulatory system and cardiovascular system. Where multiple ACEs are experienced over time, a long-lasting stress response will lead to a wear and tear effect on the body especially where there is a paucity of adult supportive relationships to provide what is referred to as “buffering” or protection.

More recently, the definition of adversity has been expended to include societal and systemic causes. These include violence, bullying and intimidation in the child’s school or other community as well as poverty and gross inequality. The body’s stress response does not distinguish between different types of threat, it simply recognises when there is a threat and responds with a high state of alert or hypervigilance. It is important to recognise that many of us experience some adverse experiences as children. It is the accumulation of these, especially where adult support is lacking, that can lead to health, social and personal difficulties later on.

A range of interventions, initiatives and responses can undermine and mitigate these effects. At the heart of these are relationships with others. These might include protective parents and carers, a therapist, a teacher or other adult who supports and nurtures the child in a way that is protective and with an emphasis on helping them to feel safe and cared about. In this way the stress response need not be unnecessarily triggered by anxiety and fear and can either remain balanced or quickly return to balance (homeostasis) and free of trauma. 

The ACEs model is not and should not be used as a diagnostic tool, but its value in helping people to understand where their difficulties may have come from can be life affirming. Recognising the links between adverse and often traumatic experiences and current life situations provides insight, helps remove self-blame and criticism and in many cases promotes healing and hope for the future. Perhaps more importantly, it acts as motivation for our society to consider, as far as possible, attempting to reduce and even remove many causes of chronic adversity from children’s lives. At the very least we should ensure children experiencing factors which lead to adversity, have a reliable and trusted adult alongside them, whoever that may be.

Last year, Dr Nadine Burke Harris was appointed Surgeon General in California.

Rod Salter