Focusing on childhood adversity can transform health and social care in Scotland

26th April 2016

SRN’s Lucy Mulvagh shares some thoughts about ACEs (Adverse Childhood Experiences) and the ‘theory of everything’.

This month I had the fantastic opportunity to attend a talk given by Jane Ellen Stevens, Founder and Publisher of the ACEs Connection Network, as part of the GCPH Seminar Series.

Afterwards I immediately went online and began devouring as much information as I could about adverse childhood experiences. The more I learn about this fascinating theory, the more I believe it could be the game-changer we need to achieve transformational change in health and social care in Scotland.

What are ACEs?

ACEs, or adverse childhood experiences, are traumatic events that can have long-lasting negative impacts on health and wellbeing.

The original research on ACEs is known as the ‘CDC-Kaiser Adverse Childhood Experiences Study’. It was led by Dr. Vincent Felliti of Kaiser Permanent and Dr. Robert Anda of the CDC (Centers for Disease Control) from 1995 to 1997 in California, USA. This excellent film is a brief introduction to the research.

The ACEs Study involved a short, anonymous survey about adverse experiences, current health status and lifestyle habits. It asked whether people had encountered any of the following ten experiences when they were under 18 years old. Each positive answer scored one point, so someone who had never experienced childhood adversity would score ‘0’, whereas someone who experienced all of these would score a maximum of ‘10’:

10_areas_trauma_image

There are, of course, other causes of childhood trauma, but the researchers chose these as they were the most prevalent. Subsequent ACEs studies – and there have been a lot! – have added tailored questions to the core ten: for example, one study with a predominantly immigrant community also asked whether a member of the household had been subject to deportation.

While the ten core questions cover a wide range, Dr. Felliti notes that what they all have in common is that that they are well-hidden – “by time; by shame; by secrecy and by social taboo.”

If you’re interested in calculating your own ACEs and resilience scores you can do so here: https://acestoohigh.com/got-your-ace-score/. When I took the test myself and realised I had a score of 5, I knew I had to find out more.

What did the ACEs study find?

One of the most striking things about this landmark public health study is the sheer numbers involved – over 17,000 people took part. Another key factor was that the vast majority of participants were white, middle class, college educated, in work and with access to good quality health care.

Both these facts make it extremely hard to dismiss the main findings, which are that ACEs are:

  • extremely common – two-thirds of participants had at least one adverse childhood experience;
  • strong predictors of poor health and social problems in later life; and
  • the leading determinant of health and social wellbeing at the population, community and individual level

The ACEs study conclusively proves that people who experience childhood adversity are far more likely to experience chronic disease, mental ill-health, premature death and violence in adulthood.

ACEs_table1a

Also, ACEs don’t tend to happen alone – if you’ve experienced one then there’s an 87% chance you’ve experienced two or more.

And, finally, the higher your ACE score, the worse your outcomes will be in adulthood.

ACEs_table2_image

ACEs_table3a

What does all this mean?

Although the ACEs findings are staggering in and of themselves, it’s when they’re combined with other scientific research that we can begin to better understand – and ultimately resolve – some of society’s greatest health and social problems.

An emerging ‘theory of everything’ or ‘unified science’ of human development brings together epidemiology, i.e. the original and subsequent ACEs studies with further research on:

  • the effects of ACEs-related toxic stress on the brain (neurobiology) and body (biomedical);
  • the epigenic consequences of toxic stress, or how ACEs are passed from one generation to the next; and
  • resilience, or the way in which the brain and body can heal

Scientific research has shown that toxic stress physically damages children’s developing brains. Toxic stress is defined as too much stress, i.e. much more than the normal and healthy amount of stress that aids development.

Exposure to childhood adversity causes toxic stress, which negatively affects brain development and can lead to people with high ACEs scores engaging in high-risk and anti-social behaviour. For example, science has shown that ACEs affect the pleasure and reward centres of the brain that are associated with substance dependence. MRI scans of children subject to ACEs have shown that the area of their brains responsible for ‘fight, flight or freeze mode’ will develop disproportionately compared to the areas of the brain associated with learning.

Personally, I find this argument compelling. Some could say that of course people who experienced childhood adversity will engage in high-risk behaviour, such as smoking, high alcohol or drug consumption, because they had a bad childhood. But actually there’s a scientific reason why some people are predisposed to engage in activities and behave in a way that is a great risk to them and those around them.

Even if we do consider risk-taking behaviour as merely ‘bad’ behaviour, as Dr. Felliti notes, many of these ‘risky’ lifestyle choices that can lead to chronic ill-health, such as smoking, drug-taking, using alcohol, unsafe sex and so on are, in context, “effective coping devices” that people use to help them cope with the impact of their adverse experiences. They are “personal solutions to problems that are well hidden”.

Chronic toxic stress not only negatively impacts on the brain, but it also affects our physical health in the longer term, particularly when experienced by young, developing bodies. It can lead to a bewilderingly wide range of chronic diseases. Even people who experienced childhood adversity but who didn’t subsequently engage in health risk activities are more likely to develop heart disease and cancer because of the effect of chronic toxic stress on their developing immune and hormonal systems. Biomedical researchers say that childhood trauma is biologically embedded in our bodies, which is why people with higher ACE scores can die up to 20 years earlier than the average citizen.

The ACE Pyramid neatly sets out a conceptual framework for the ACEs study:

ACEs_pyramid_image

The third element of the ‘theory of everything’, epigenics, is the study of how social and other environments affect human genes. It has shown that toxic stress alters genes and causes long-term changes in all parts of our bodies and brains. It’s also demonstrated that these changes can be transferred from generation to generation. So parents with high ACE scores can pass these onto their children.

Why do I think this is so important?

Childhood adversity and trauma is the most basic cause of health risk behaviour, morbidity, disability, and mortality and it places an enormous demand on health and social care systems and support. To me, therefore, it’s clear that something has to be done to tackle ACEs.

However it’s easy to imagine that, having been presented with the overwhelming evidence about ACEs, toxic stress and epigenics, we can end up thinking, ‘Well, some people have just got broken brains, and there’s nothing we can do about it!’

But it’s not all bad news, and this is where the final element of the ‘theory of everything’ comes in – resilience. Resilience is the ability to adapt well to adversity, trauma, threats or significant sources of stress. There are many aspects to resilience, which is a huge subject that I unfortunately don’t have space to go into here, but one of the initial things that has struck me about it is its links to assets-based approaches and recovery, particularly the CHIME framework.

As Aces Too High notes: “the brain is plastic, and the body wants to heal.” Scientific evidence has shown that brains and bodies continually change in response to their environment. Stopping toxic stress and using trauma informed and resilience building practice can help us physically and mentally undo many of the negative changes caused by ACEs.

Roadmap_Resilience_image

I believe that using human rights based and recovery oriented approaches can help services and those that access them become trauma informed and strengths-based: helping to shift the balance of power; focusing on what’s happened to people rather than what’s wrong with them; on what they CAN do rather than what they cannot.

A growing number of people around the world are fundamentally changing their approach in areas such as diverse as education, health and social care, the courts and justice system. One example is paediatrician Nadine Burke Harris – her TED Talk is well worth a watch.

What now?

Adverse childhood experiences do not necessarily result in an immutable and dreadful fate; they’re a tool for understanding population and community-level health as a whole. At the individual level, we can use our ACE scores to better understand our own risk for health and social problems, and use that knowledge to empower us to make changes for ourselves, our children and future generations.

I’d really like to see ACEs studies and the ‘theory of everything’ being developed throughout Scotland. It seems to me that if we can transform our support systems and have them focus on eradicating the negative impact of ACEs and preventing childhood trauma we would begin to see unimaginable improvements to everyone’s health and wellbeing.

Useful resources

As well as the links scattered throughout this article, a useful resource is the ‘Roadmap to Resilience’ toolkit.

NHS Lanarkshire have also produced a great wee film about trauma and the brain.