Why I worry about the ACE-aware movement’s impact
By Whitney Barrett on 09 October 2018
There’s more to trauma than simply an ‘adverse childhood experiences’ score, says this principal educational psychologist
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
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