From Ireland to St. Louis. Adverse Childhood Experiences. Impact upon physical health. Prevalence of ACEs in the original study

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1 A project supported by the European Union s INTERREG VA Programme, managed by the Special EU Programmes Body From Ireland to St. Louis Adverse Childhood Experiences -Working together to address an epidemic Trevor Spratt Professor in Childhood Research Trinity Research in Childhood Centre Trinity College Dublin Adverse Childhood Experiences 10 item questionnaire on areas of abuse and family dysfunction experienced in the first 18 years of life. A majority of the population have an ACE score of 1 or more. The higher the score, so increases an individuals probability of experiencing a range of poorer than average health and social outcomes over their lifecourse. The mechanisms for translation include physiological embedding of trauma, distorted psychological processing, risk taking behaviours and detrimental health choices. Prevalence of ACEs in the original study Impact upon physical health ACE Score 0 48% 1 25% 2 13% 3 7% 4 or more 7% Prevalence Compared to those who have an ACE score of zero, those with a score of 4 or more are: 4 times more likely to develop type 2 diabetes 3 times more likely to develop respiratory disease 3 times more likely to develop heart disease With an ACE score of 7, life expectancy is 60 years 1

2 ACEs and mental health A universal research finding In all cases the pattern has been the same the greater the number of adverse experiences in childhood, the greater the likelihood of health problems in later life. Center on the Developing Child at Harvard University A project supported by the European Union s INTERREG VA Programme, managed by the Special EU Programmes Body ACEs and poverty Child mental wellbeing & income Source: Scottish Health Survey 2

3 In rich and relatively equal societies like Sweden there are still ACEs Children who witness domestic violence and then lose a parent double their chances of developing a drug use disorder in later life. Numbers of ACEs progressively increase the odds of receiving a disability pension in early midlife (males with ACE 4+ = 7 fold odds). The greater the number of ACEs the more likely women will report higher pain intensity and larger pain distributions in late pregnancy. adults who had previously been in care homes: Those with ACE scores of 4+ were 2.5 times more likely to receive means tested social assistance in early adulthood, compared to with those with a score of zero. Relationship between poverty and ACEs We find higher ACE scores in the poorest communities there are a number of explanations: ACE scores influence economic outcomes at an individual level Poverty creates stresses that lead to changes in adult behaviours bequeathing ACEs to children But poverty in and of itself is not an ACE and income inequality is an important consideration A project supported by the European Union s INTERREG VA Programme, managed by the Special EU Programmes Body 3

4 A public health approach to teenage pregnancy There has been a 41% reduction in the under 18 conception rate in England between 1998 and 2012 This is the lowest rate since 1969 when data collection began Both maternity and abortion rates are declining but the overall reduction in births is steeper at 46%. Two ways to address a public health disaster Emergency Response: Frank Pantridge designed and fitted the first portable defibrillator in an ambulance in Obituary: it was only after years of scepticism that a defibrillator was fitted in every ambulance. Preventative Response: Deaths by heart attack have fallen by 40% since the early 1970s. Researchers conclude that 58% of the mortality decline is attributable to reductions in the major risk factors, principally smoking. Questions Could taking a public health approach to ACEs result in a similar reduction to that of teenage pregnancies? How is our system presently calibrated to prioritise emergency response to incidents, or to prevent longer term damage individuals experiencing multiple adversities? What would a public health approach to ACEs look like? It would have to have regard to the following: The ACE footprint of the country The level of income inequality Is there universal access to health and social care? Is there an all of government ACE approach to policy? Do services agree an ACE philosophy and conjoin services? Are communities ACE aware? Research to produce an evidence base of what works in ACE prevention and amelioration. ACE footprint in Wales 4+ 14% 2-3 Ace 13% 1 Ace 20% 0 Ace 53% Ace footprint in Saudi Arabia % 2-3 Ace 27.4% 1 Ace 23.6% 0 Ace 20.3% 4

5 ACEs in young adults in 8 eastern European countries: Bellis et al Physical abuse: 6.9% Rep of Macedonia to 41% Albania Sexual abuse: 3.5% Lithuania to 19.1% Albania Emotional abuse: 2.9% Russian Federation to 26.5% Albania Emotional neglect: 7.4% Montenegro to 18.4% Russian Federation Domestic violence towards mother: 1.4% Rep of Macedonia to 30% Albania Problematic use of alcohol by household member: 6.4% Turkey to 30.3% Latvia Parents separated or divorced: 3.8% Rep of Macedonia to 42.3% Latvia Depressed or suicidal household member: 5.6% Montenegro to 18.8% Latvia Household member incarcerated: 2.3% Romania to 8.3% Latvia/Turkey Drug abuse by household member: 1.4% Russia to 4.8% Latvia The MACE research group Members: Lisa Bunting, Delores Carroll, John Devaney, Gavin Davidson, David Hayes, Stan Houston, Ann Lazenbatt, Lian McGavock and Marlene McGibbon What do studies on this Island tell us about ACEs? Prevalence of ACEs in a university population: Associations with Social Services contact McGavock and Spratt 765 respondents. Those with 4+ ACEs were over 23 times more likely than peers with 0 ACEs to have had social services contact Ace Score Number % Witnessing Domestic Violence and ACE scores Following a pilot study an additional question on male directed abuse was added, 25 students reported this (3.3%), with 43 reporting female directed (5.7%). Of the 68 (9%) students who reported witnessing domestic violence, 92% report at least two additional ACEs and 82% report at least three additional ACEs (score of 4 or more). Forty two percent also reported contact with social services. In a UK study Stanley and colleagues found that in 83% of cases referred because of DV, the family either received a letter only or no further action. ACEs in cases of teenage suicide Devaney et al. ACEs and suicide attempts in childhood & adulthood Mean Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 5

6 Caring for a parent with a mental illness signifies higher ACE scores McGibbon et al. carers caring for parents with mental illness presented clusters of ACEs that were not a feature for those caring for parents with physical disabilities. This helps us to identify those children experiencing multiple adversities within a previously undifferentiated population. Children referred by Standard Report Form to Social Workers by DoCs - Dolores Carroll Of the 36 cases surveyed, only 8 children scored below 4. The large majority of these children had ACE scores at what we might term clinical levels. In population studies only around 15% have scores of 4+; for this group of children their mean ACE score was Incredibly, almost half the children (49%), had scores at the very highest levels of 8+ ACE profile of mothers with children subject to SRFs Intergenerational transmission of ACEs These data demonstrate that an incident leading to referral to social workers needs to be analysed to discern both the causes (child's ACE score) and the causes of the causes (parent s ACE score). Such profound intergenerational damage is unlikely to be ameliorated and halted without the provision of long term therapeutic help. Transmission: Wales compared with people with 0 ACEs, those with 4+ were: 4 times more likely to be a high risk drinker 6 times more likely to have had or caused a teenage pregnancy 6 times more likely to smoke tobacco or E cigs 11 times more likely to have smoked cannabis 14 times more likely to be a violence victim in last 12 months 15 times more likely to have committed violence in last 12 months 16 times more likely to have used crack cocaine or heroin 20 times more likely to have been incarcerated Preventing intergenerational transmission 6

7 Routine enquiry for history of ACEs in the adult patient population in a general practice setting 2018 Coping with ACEs Mark Bellis Childhood adversity was more prevalent among younger patients and those currently living in more deprived areas but did not differ by gender or ethnicity. A positive relationship was found between ACEs and certain lifestyle factors (smoking and unhealthy weight) and ACEs and long-term health conditions. Patients with 2 ACEs were over two and a half times more likely to suffer from asthma and almost three times more likely to have complex health needs and be living with multiple long-term conditions, compared with those with 0-1 ACEs. Feel you can overcome hardship and guide your destiny Equipped to manage your behaviour and emotions Grounded in cultural traditions connected One or more stable, caring child-adult relationships ACE awareness in Spokane High School Challenge: One third of the class had ACE scores of 4+. Best predictor of health, attendance and behaviour. Education success related more to ACE score than family income. Intervention: Staff informed about the impact of ACEs and they helped pupils focus on building resiliency and developmental skills, promoted relationships with care-givers (attachment) and encouraged self regulation by sharing emotional experiences. Results: 75% less fights, 83% drop in suspensions (from 798 to 135) and improved graduation rates. Buffering effect for high ACE score: One positive and sustained relationship with an adult Question for adults with ACE scores of 4+. As a child was there an adult you trusted and could talk to about your problems? Of those who responded always 8% reported problem drinking, 12% use of cocaine and heroin and 12% had been imprisoned. Of those who responded never 21% reported problem drinking, 21% use of cocaine and heroin and 41% had been imprisoned. ACE Resilience Survey 2017, Mark Bellis et al. How well are social workers (or any profession) positioned to provide services to those with high ACE scores? Social workers are neither well placed to provide specialist services to families with multiple needs where the risks are intergenerational in nature because of their narrow concentration on child protection issues in the present, nor are they likely to meet the needs of a broader range of referred families where the problems are identified at a much earlier stage, because such families do not reach child protection thresholds. (Hayes and Spratt, 2009) Triage systems have limited child safety goals and use their own measures As a result of implementing Differential Response, Family Involvement Strategies and the Signs of Safety approach in Minnesota there were: Fewer investigations Less repeat child maltreatment Less court ordered involvement Less children in placement Fewer days of foster care More family involvement 7

8 Interventions in populations with challenges more akin to chronic disease than immediate harm Are brief interventions essentially providing effective short term symptom management? Do we need to develop new services that recognise the long term consequences of adversities experienced in childhood? What would such services look like? Systems are not presently calibrated to respond to a public health disaster This public health disaster has been hidden from view. Our society has treated the abuse, maltreatment, violence, and chaotic experiences of our children as an oddity that is adequately dealt with by emergency response systems... they are a dressing on a greater wound...these children vanish from view and randomly reappear as if they are new entities in... adulthood as clients with behavioral, learning, social, criminal, and chronic health problems... Robert Anda The big goal 46 Mobilizing action for resilient communities Adverse Professional Experiences (APES) My professional identity serves to make me different from professionals from other disciplines. Y/N My professional status helps distance me from the experiences of my clients. Y/N I think more about proximal causes than the connections between ACEs and later life difficulties. Y/N Nobody ever told me about ACEs when I trained. Y/N I m a doctor/teacher/nurse/psychologist not a social worker so it s not my job. Y/N I m a social worker and it s not my job to be interested in much more than immediate child safety. Y/N 8

9 Adverse Professional Experiences (APES) I change jobs very often and I don t really build up lasting relationships with my clients. Y/N My first preference is for short term interventions. Y/N I have a high ACE score and haven t ever thought of it s impact upon my life or the lives of others. Y/N I have a low ACE score and think the impact of ACEs is overstated. Y/N Lower scores indicate potential for successful preventative and ameliorative interventions, higher scores increase the probability of poor outcomes for clients Our assessment practices are often like those of Cypriot businessmen, whose.. eyes see sharply, but not very far. Colin Thubron So it s important to consider the causes of causes Sir Michael Marmot Words of warning ACE score composites An ACE score is probabilistic, not deterministic: Individuals with higher ACE scores may have a higher mountain to climb but many do successfully climb that mountain Individual scores mask different composites: this means that services should not be one size fits all Our knowledge base in relation to what works in terms of effective interventions is not very far advanced. CHILD A Physical abuse Sexual abuse Psychological abuse Physical neglect Emotional neglect CHILD B Parent substance abuse Loss of parent Parent with poor mental health Domestic violence against mother Parent in prison Two questions from David Finkelhor 1. What are the effective interventions and responses we need to have in place for effective ACE screening? Is it ethical and justified to screen for conditions when proper treatment cannot be assured? 2. What are the potential negative outcomes and costs to screening that need to be buffered in any effective screening regime? For example, an increase in referrals to social workers resulting in more investigations, flooding the system and not resulting in provision of effective services? Test criterion David Finkelhor The initial criteria for deciding among screening approaches should be the degree to which differently screened groups get access to, complete and derive any benefit from the intervention. 9

10 Examples of evidence supported intervention programmes There are a few evidentially supported preventative interventions: The Family Foundations programme (during pregnancy) has been found to reduce couple conflict, with improvements in children's behaviour noted at ages 3 and 7 The Lieberman model of Infant-Parent Psychotherapy has been found to reduce symptoms of trauma. It is delivered in weekly one-hour sessions over a year ( by therapist or SW). The Early Intervention Foundation There are no simple solutions: No single intervention is sufficient, we require a range of interventions to address multiple needs. Addressing adversity for high-risk cases requires longterm, individualised support. Evidence based programmes are not an easy fix: They need to be carefully delivered according to programme requirements. Effective interventions require a suitably qualified workforce: Interventions can either provide benefit or cause harm. The Philadelphia ACE Task Force Strengthen networks among professionals addressing ACEs Enhance research strategies to better understand the challenges we face and their possible solutions Partner with communities affected by trauma to better understand and identify related concerns and build awareness about ACEs and trauma, develop advocates, and co-create solutions Educate policymakers and advocate for systems change to better support trauma-informed approaches. Key take home messages We don t know what the island of Irelands ACE footprint looks like a population study would address this As with Wales and Scotland, the results could inform an all of government(s) policy approach to ACE prevention and amelioration We can act now in the following areas: Petitioning professional regulatory bodies to direct education providers to include ACE training in professional qualifying programmes (with post qualifying requirements too) Developing and taking forward initiatives such as the CAWT, building inter-professional alliances and raising community awareness. And promoting Warm relationships! 10