Adverse Childhood Experiences (ACEs)

I'm here tonight to talk about adverse childhood experiences, which often gets shortened to ACEs, and I'll try and go back and forth between that language. This is such an interesting time because we are all learning how to cope with disconnection, we're learning how to cope with new equipment so it's really interesting to think about human experience in the midst of coronavirus time, which might sound obvious, but actually that emotional experience of learning to do this is part of why I'm filtering that into all of the things. I think about relationships, emotional experience, how you manage that and then how that fits into ACEs. Tonight's learning outcomes: I just wanted to help you to be aware of what ACEs means and what the research around ACEs is telling us and to know that there is now an international movement around ACEs and to think about what some of the debate is around that, and especially to help you to think about what the relevance of all of that is for counsellors.

I've structured tonight's presentation around four themes, which I'll do as questions. What are ACEs? I would like you to leave really confident about that. Why is this information useful for counsellors? Is there debate over ACEs and what would be the next best step? These are our four pieces to tonight.

I just wanted to do a teeny bit of background, which unpacks a bit about what Collette so kindly said there at the beginning, because it raises a really interesting question. This is my background. I was a research scientist and developmental or child psychologist here at the University of Dundee for nearly 20 years and for the last, nearly a decade now, I set up my own training enterprise as 'Suzanne Zeedyk' in 2011. Then by 2014, we put together an organization and a team called 'Connected Baby'. The reason that I wanted to highlight that for you is because it raises the question, how do we get science out to the wider public? The reason that I stepped away from full time academic and research work was because I got frustrated. I knew that I had access to a whole lot of information that I thought was fascinating and really important for teachers, counsellors, early years, politicians, social services, doctors and I knew that they didn't have access to it. So, the question for me became, how do we help people to know? It is the question that frames everything I do now, because I believe that everybody deserves to know this stuff. The question becomes, how do we get it to them? How do you make it accessible? What form does it need to come in? What language do we use? I think those questions are really important because I do think everybody deserves to know this.

So, with that frame, what are ACEs? Here is the story of the science of adverse childhood experiences. It starts in the 1990's with two doctors named Vincent Felitti and Rob Anda, who had begun to be confused about some of the outcomes that were happening for their medical treatment, especially as they began to get back stories that didn't always make sense to them and by back stories, I really mean experiences of their patients. This is particularly how Vincent Felitti says that the question about ACEs came to him. This is the direct quote from the obesity clinic that he was running. He said every other person that he was asking about was providing information about childhood sexual abuse and he says, "I thought this can't be true. People would know if this was true and somebody would have told me in medical school, and they hadn't". It came out of a confusion about what was happening for his patients, and that led to the Adverse Childhood Experiences Study, which was published in 1998 under this title. You can see the relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences, ACE's Study. That was published in 1998, which means that it's been around just over 20 years now. Key parts of the history of that study are that it was conducted between 1995 and 1997 in the USA. It involved seventeen thousand patients who were undergoing standard health exams, so not a specialist group in any way, not a group that was known to have experienced childhood distress, not a group that was known to have particular health outcomes, just ordinary patients undergoing standard health exams and because of the nature of the patients that were coming to the clinics, it was largely middle class and educated. In other words, not working with groups that were in particularly deprived areas. These are the key things that they found in that study.

Two key insights. The first is they discovered that if you had had childhood experiences that they called 'adverse childhood experiences', it led to key consequences for adult health. That is the key finding that comes from the ACEs studies. Let me go back. They looked at 10 experiences that were particularly common. Abuse, either physical, emotional or sexual, neglect, emotional or physical, and what they called 'household dysfunction'. Your mother was treated violently. There was substance misuse. You had a parent with mental illness, a parent in prison or parental divorce. You can see there that there are 10 experiences and those 10 have gained the most attention in the subsequent discussion of the ACEs study, although it's useful to highlight that they didn't think these were the only 10 adverse childhood experiences that you could ever experience. In other words, they are not exclusive, but it was enough to help them to start to find relationships to adult health problems. So, they were able to show, with this very large sample, a link between childhood distress (ACEs) and liver disease, heart disease, depression, suicide attempts, smoking, drug use, alcoholism, early sexual activity, partner violence, a whole range of health-related quality of life outcomes and there are others. I put those on the slide because I can fit them on. My very favourite is diabetes. Most people don't think of diabetes as related in any way to childhood distress. I think that is the key insight that is most stunning for people. We don't normally think of what we think of as medical or health outcomes as related to childhood distress. It's not surprising for many people that you might have mental health issues, problems, challenges but we live in cultures that, for the most part, have not linked more what we think of as medical conditions or diseases to childhood distress. So, the key outcome that comes out of this study is that medical problems can have a basis in childhood fear and suffering.

Now, here's the other key insight that comes out of that study. If you count the number of experiences that you had on that list that I gave you from zero to 10, you can come up with a score. When they looked across their group of seventeen thousand and now the many pieces that have been done since then, what they found was that the number of people who had said they'd had none of those experiences was very roughly a third. Those who had only one was 26 percent and two of those experiences was 16 percent, three was 10 percent and four or more was 16 percent. One of the key insights for them was that ACEs are common, they're not uncommon. They're commonly spread across a population. This was a surprise to Vincent Felitti and Robert Ands and understanding being able to document empirically that as the number of experiences you had experienced and there were types of experiences you've had went up, that it increased the likelihood of these kinds of outcomes. Now, that isn't to say there is a guarantee, but it is to say that there's a statistical relationship between the presence of childhood distress and health outcomes and those experiences are common.

Those are the two key insights that come out of that 1998 study. They came up with a model that represented what they thought they were finding. If you Google for this, you will find this all over the Web. What they tried to capture is that they thought that this is what was happening, that if you experienced adverse childhood experiences there at the bottom in the pink that led to disrupted neuro development, the stress affects the development of your brain and your body. That leads to social, emotional and cognitive impairments. It makes it hard for you to trust other people. It makes it hard for you to pay attention in school. It makes it hard for you to manage your emotions, if manage is the right word. It makes it hard for you to understand what you're feeling. It makes it hard for you to pay attention. It puts you into a stressed or hyper vigilant state or perhaps hypo vigilant state. In other words, you're really in tune with environment or you're not very in tune with the environment at all. In other words, it changes your emotional experience and then the way you engage with the world. Then, because you are in a higher stress state, you're more likely to adopt health risk behaviours like smoking, drinking, drug use and that leads to disease, disability and social problems. It increases the likelihood that you will end up in the prison system, that you'll end up in care, that you will end up with heart disease or liver disease or diabetes and a whole range of other problems. That's likely to lead to early death. Our chief medical officer here in Scotland, Harry Burns has talked about ACEs for a number of years before he retired, and he used to make the point that there are areas of Glasgow where the average rate of death is 54 years old, early death. He used to say we're not going to solve that problem by more obesity drives or anti-smoking drives. We will solve that problem by thinking about the way we love our children. I so valued him for being willing to bring this model alive by talking about love.

There are two other concepts I thought I would just highlight that are often used in the ACEs frame. One is this notion of toxic stress. They tried to distinguish between stress that is positive, stress that is tolerable, so you have serious but temporary stress responses which are buffered by supportive relationships and stress that they call toxic. It's the toxic stress that leads to the kinds of biological change that leads to the outcomes that are captured in this model. I've put in an arrow there because it highlights the word relationships. Toxic stress is prolonged activation of the stress response system in the absence of protective relationships. Relationships is really, really important to understanding what the ACEs research is telling us and sometimes that point is missed. I'm going to come back to it in a moment because what we are effectively talking about, once we're talking about relationships, is attachment.

The other word that's often talked about in the ACEs frame is buffering. In other words, that relationships buffer the stress. I would be more likely to say it gives you a safe base, a secure place. You don't have to go through the stress, the adversity that you're facing alone, but the word that the ACEs frame is more likely to use is the word buffering.

Increasingly, when I talk about ACE's, I use this term, I talk about childhood suffering. When you are dealing with the distressing events that are overwhelming, that are scary, that are painful and you don't have anyone to help you with, what you're talking about is suffering, and in fact, I was tweeting this morning about the situation faced by a lot of children in the country now about going hungry, and I was linking that to the kinds of experiences that are captured in an ACEs frame. We're talking about childhood suffering. We can come back to that during questions, if you would like. The part of the reason I wanted to highlight this here is because it highlights what language do, we use to help people to think about the kinds of experiences that are at the heart of what we're talking about when we're talking ACEs?

OK, a few more things here. There's really quiet a lot of interest in ACEs now. This is a photograph from a big event that we had in Glasgow in 2018 where two thousand people came together for a one-and-a-half-day event where one of the leading ACEs campaigners, Nadine Burke Harris, came to speak. You can tell from that image that there are a lot of people who are now interested in having this conversation in the public.

One of the ways that that interest really came about is through this film called 'Resilience, The Biology of Stress and the Science of Hope'. I wanted to highlight it in case you have a chance of seeing it in your area. Very sadly, just last week, the news was announced that Jamie Redford, who was the director of that film, has passed away and indeed he died at only 58 due to liver problems, which he himself put down to a chaotic childhood. If you have trouble seeing the film itself, here is the trailer. You can Google for that as soon as this is finished, and it gives you a sense of what the film is like. It becomes very interesting to think, why did it take 20 years for this information to get out to the public? One of the ways in which we have found is most effective in reaching this to the public here in Scotland and beyond our borders is through a film. In other words, not just the science itself, but by a filmmaker who translated that to make it more accessible to the public.

Okay. 20 years on, here's a piece that was published to reflect on that in the American Journal of Preventative Medicine, which published the original piece in 1998. Here's a summary of some of the things that have happened. There have been at least 4300 articles that have been published around the ACEs theme in those 20 years. So, we're a long way on from just that first study. There are a number of additional types of ACEs that have been discussed, reflected on, were brought into the discussion, bullying, birth, bereavement, boarding school, coming from a violent community, racism. There are now additional models to explain ACEs beyond just the triangle that I showed you. Quite a lot of thinking has now gone on in those 20 years. I wanted to highlight this economic analysis that was published in The Lancet in 2019, which looked at the economic consequences of childhood suffering. What they showed was that they thought that only a 10 percent reduction in the prevalence of ACEs in North America and Europe would yield in annual savings of one hundred and five billion dollars. With only a 10 percent reduction. So, if it's okay to be my earlier point, when the government talks about how much it costs to feed hungry children, if we did an economic analysis of how much that might cost us against how much we might save, we might see the problem rather differently.

There's an international ACEs movement, it's really expanding. There are centres of activity in the USA, Scotland, Northern Ireland, Canada and in the Netherlands. As this spread, I think the rate of spread is really picking up. Canada and Netherlands just really established their presence this year.

In case you are really interested by what I'm saying, you might be interested to know that ACE aware nation, which is the base here in Scotland, is just about to announce a whole ACEs Conversation series and you can see that the first one takes place on Thursday talking about ACEs and human rights. Anybody in the public is welcomed to come to that. You can Google for that or find it on the ACE aware nation website. I just wanted to highlight all the different things that ACEs now intersects with. ACEs and poverty screening, the language of suffering, international perspectives and relational leadership. This is just our attempt to help the public to really engage more deeply and broadly with this way of understanding childhood suffering.

If you want to know more resources, Nadine Burke Harris has a great TED talk out. She is one of the key campaigners. She also has a great book out called 'The Deepest Well'. This is, I think, a really good summary of what the ACEs research shows. Here's a BBC radio interview, I'm just trying to highlight here. This has been on BBC since 2016, it's still on the website. In other words, people were talking about this, but a real interest did not come about until the last couple of years. I have a book out called 'Sabre Tooth Tigers and Teddy Bears', in which I talk about ACEs and even a new movie available on Netflix is called 'Hillbilly Elegy'. That's based on a book by a lawyer named Vance and in that he tells the story of his life and he, too, talks about ACEs. I'm just trying to say there are a whole range of things now out there, if you are interested, but to also show how public interest is really rising in this topic.

So, you might, I hope, by now be thinking, okay that sounds like a lot. How is it particularly relevant for counsellors? Well, I think there are three keyways that this is really important to you. The first is that I think ACEs extend attachment theory. This is not yet talked about a lot, but I now try to talk about it wherever I can. This is a paper by a guy named Simon Partridge's that was published in 2019, and in it he tries to track the real overlap between ACEs and attachment theory. You can see that the title of his paper is 'The Origins of the Adverse Childhood Experiences Movement and Child Sexual Abuse'. He reminds us that this insight about adult health outcomes begins with child sexual abuse and therefore clear suffering. He says in it, 'the paper draws attention to Bowlby's own use of the term adverse childhood experiences, which is not widely realized'. He says that if Bowlby, who is really the grandfather of attachment theory, if he had lived a little bit longer, he would have welcomed the discovery of ACEs. I think there's a whole lot to understand in this, and I think there's much more to unpack once we realize that this link exists.

Here's a second way that I think really applies to you. Many sectors don't know about trauma. Many of you watching this deal a lot with trauma, so the impact of trauma is familiar to you, the importance of recovery and healing is familiar to you, but there are a lot of other sectors who don't know about it. This is a piece written by a paediatrician in the NHS in October 2017. He had this to say when he began to learn about trauma and ACEs. 'What is extraordinary, and to be frank, a betrayal of patients and clinicians on the part of those responsible for medical education is that we never talked about, much less seriously taught about the lasting effects of trauma'. This was news to him. 'We were taught that diseases were due to the interaction of human biology and the environment, but human experiences were barely part of the picture'. You know that human experiences matter. You know things that would be valuable to people in other sectors that are a surprise to them. So, it highlights the importance of what you do and if helping to spread the insights that you have much more widely.

Thirdly, one of the ways that I think ACEs impacts on counsellors is that it actually prompts reflection on the nature of therapy itself. This is a piece written by a woman named Cissy White on the ACEs too high website and you can see that it's called 'How Facing ACEs makes us happier, healthier and more hopeful'. She has what I think is a sobering observation to me. She says that when she found out about ACEs, she was overwhelmed with the joy that she felt radical relief and that what she experienced was a profound sense of validation. Then she says something that I think gets us to reflect, she says 'this one study has done more for me than decades of therapy in helping me to understand the impact of PTSD. I want that for others' and that she thinks this information should be shared. I think that is a really interesting piece, and it makes one think about what the nature of therapy is and that she had spent decades in therapy and understanding the impact on her biology of the distress she had felt as a child, had a dramatic impact on her understanding of what she was dealing with and therefore her understanding of herself. I think that makes for a very interesting challenge. A hopeful challenge from the ACEs research on what that might mean for our understanding of healing and therefore for counsellor activities.

That's a very quick history, it feels really important now to highlight that there is debate over ACEs. As awareness of this has grown and become more widely known in various sectors and amongst the public, some very vociferous debate has grown up. I just want you to be sure to be aware of that if you expand on what I am talking about tonight and you start to do your own research. Here are five areas of debate. One is around scoring. In fact, I think this is the key debate and it may be in questions. We can come back to this. This is Nadine Burke Harris; you've already seen this image for just a moment. She is one of the leading campaigners for ACEs. In fact, she is now the leading chief scientific officer for California. In other words, she has a very key post in terms of California's medical services. You can see that under her leadership, California has begun screening for early childhood trauma this year in January. She feels very strongly that this is the best way to address childhood suffering, that medicine and paediatrics has not been very good at this, so they now do a form of universal screening. You can see the rest of that highlight, it says 'critics urge caution'. Not everybody is sure that screening is the best way to go about this. In fact, a piece came out in March of this year, led by Robert Anda, who is one of the leaders of that original 1998 study and you can see that here he is talking about the adverse childhood experiences score in which he reflects on the strengths, limitations and misapplication of that idea. The concept of screening and scoring and the measurement of trauma to a numerical scale is exercising quite a lot of debate about which some people feel very, very strong.

Here's another area of debate. Some people feel that it distracts from poverty and societal context. Some people have argued very strongly that we need to pay attention to the environment in which children are developing and that an ACEs concept perhaps can be too individualistic. That has made it to the newspapers. Here's a piece in The Scotsman in which several of us were interviewed, including myself, in 2019, and it was picking up on this debate. Is it a light bulb moment where we really understand that the child is suffering due to biological consequences or is it a magic bullet for social ills? That picks up on this debate around attention to societal context. Some people are worried about the language, whether ACEs is the best language. Here's a piece published in 2018, Why I worry about the ACE aware movement impact and you can see that Whitney Barrett, who's an educational psychologist, says there's more to trauma than simply an adverse childhood experiences score. So, the word trauma is preferable in some people's view. This was my response to that piece in which you can see that I've said I celebrate the ACE aware movement and that I think putting an understanding of trauma into the hands of the public helps to reduce human suffering. In many ways, this is a debate about the language that we use to talk about those experiences. Some people are worried that it might trigger memories of trauma and childhood experiences. Should systems be being engaging in those kinds of questions? If we come back to Cissy White's piece, she had this to say. In other words, as someone who has experienced ACEs and now deals a lot with systems, she says this. This is a direct quote from her piece, 'people say to me, won't it depress people? Isn't it triggering? Won't it upset them?' She says 'fear is what I often fight when talking about ACEs, but it's not my fear. Is the fear that others have about all things ACEs. I don't think this fear actually belongs to those of us who have lived with ACEs'. That speaks to the importance of having people with lived experience as a central part of this discussion rather than the professionals who are running systems.

Finally, I think there's an issue of power involved here. Who decides what language to use, who decides how experience is talked about, who decides how it is measured and conceived? I think we need to talk more about power. Lisa Charry and I have been having several podcast conversations, and our next one is due to take place on the 3rd of November. If you're interested, I think that there are still places for that. One of the things that we are talking about in that conversation about ACEs is indeed power. All I've tried to do there is to highlight that there is debate and what I think some of the key themes are. Interestingly, a lot of that debate did not exist until ACEs became much better known. There are now more voices involved in it. I welcome that debate because if that has more attention drawn to childhood suffering and its consequences, then I think the debate is welcome. We weren't having that debate before and there's a whole lot more people now aware of the impact.

As I wind up, I hope some of you might be thinking, okay what would be the best step for me to take next? Here I just have one as the best next step. I think if you listen to real life stories of coming to ACE awareness, it helps us to understand the power of this insight. I'm just going to highlight a few of them. This is Michelle Brennan Jones, and you can find a video of her on the Connected Baby YouTube channel. She talks about how understanding about ACEs helped her recover from that and helped her to get sober and not depend on alcohol as a way to self soothe in her adulthood.

On the ACE aware Scotland YouTube channel, there's an interview with Kevin Neary. Kevin Neary is a former prison inmate, and he talks about the difference that it made to his understanding of how the childhood chaos he had experienced had a direct impact on how he ended up in prison for a number of years in his adulthood.

This is Suzanne McCafferty. She's a primary head teacher. She talks about what it meant to her to learn this and how that changed the behaviour policy that they used in school. They ripped it up and they now have a relationship agreement. That response to childhood behaviour in schools is still considered quite radical by some people.

I've mentioned my book, but I made a point of telling a lot of stories about coming to ACE awareness in that book because that helps to bring it alive for people to not just give the information, but to tell the stories of how people are putting it into action.

If you really want to know about the origins of how we came to really have an awareness of ACEs embedded here in Scotland, it starts with the police. It starts with the violence reduction unit in 2004. So, if you would like to know more about how culture is changing, you can have a look at this video on the Connected Baby YouTube channel. You might ask, okay Suzanne, why do you want me to seek out real life stories of awareness? Why did you choose that? This is my answer.

I think that those real-life stories shine a light on the power of your own work as counsellors. What you try to do so often, perhaps at the core of your work, I think of as you want to help reduce suffering. I think that the power of real-life stories is that they show the impact that it makes when people begin to find a way of reducing the suffering that they have been carrying for the whole of their lives and I think that's an absolute connection to what you do.

Thank you for that effort.