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Adverse Childhood Experiences and ESSENCE: a complex story

Louise Marryat's latest blog entry

[Posted on 5 February, 2019 by Louise Marryat]

The Adverse Childhood Experiences (ACEs) questionnaire was designed for a health insurance company in the US in the 1990’s after a doctor noted that many of the patients he was seeing seemed to have experienced adversity in childhood. The ACE questionnaire asked adults to reflect on whether they experienced any of the following things before the age of 18: sexual, physical or emotional abuse, emotional or material neglect, having a parent in prison, or with substance misuse or mental health problems, having parents who have separated or died, or witnessing domestic violence. Results suggested that the more of these ACEs a child experiences, the higher their risk of poorer physical and mental health, economic and social outcomes across the life course (Felitti et al, 1999).

There has been a surge in interest in ACEs in Scotland in recent years. It has recently been estimated that more than half of Scottish children aged eight years have at least one ACE (out of a possible seven which were able to be measured), with 10% having three or more. Levels of ACEs varied by background characteristics, for example, 30% of children living in the most deprived households experienced three or more ACEs, compared with around 3% in the most affluent (Marryat and Frank, 2019).

This interest in ACEs has, at least in part, led to the Scottish Government’s creation of the Scottish Psychological Trauma and Adversity Training Plan, funded by a £1.5million package. The creation of a more compassionate frontline workforce is a noble cause and undoubtedly, those advancing the ACEs movement want nothing but the best for those who have experienced ACEs. It is, however, increasingly being questioned whether the ‘ACEs movement’ is having unintended consequences. For those working with the current generation of children, the idea of a child reaching the magic number of four ACEs and then being written off as doomed for life is hard to get away from. Anecdotal reports of school staff referring to children as a number, ‘well, of course, they’re a four’, have been aired. We also need to consider if we are adding to the stigma experienced by lone parents, or parents with substance misuse or mental health issues through our discussions of ACEs? Twenty years on, and in a different cultural climate, are the original ACEs still relevant, or are there others which should be considered? And of course, we need to ask if we should not still consider and support the child who had one, very traumatic ACE, or the 20 year old student who suffered multiple forms of abuse, but is over the threshold age for ACEs? The ACE scale has not received any real psychometric scrutiny: each ACE is given the same weight to keep things simple, however, some will arguably have more impact than others. It is all too easy to be drawn into the score as a fixed entity, and to forget that individual experience is complex, and outcomes are also related to wider resources, support and resilience.

But what does this have to do with ESSENCE? Colleagues at the GNC, have found evidence that children with higher levels of neurodevelopmental disorders are at increased risk of experiencing ACEs, in particular emotional abuse/neglect, physical neglect, physical abuse, and sexual abuse. This was still the case even when compared with a twin within the same household who did not have any neurodevelopmental disorders. We currently know little about the process through which this interaction between neurodevelopmental disorders and ACEs occurs. This will form the next stage of our research into the complex world of ESSENCE and ACEs.

[This is a blog. The purpose of the blog is to provide information and raise awareness concerning important issues. All views and opinions expressed are those of the writer and not necessarily shared by the GNC.]

Dinkler, L., Lundström, S., Gajwani, R. , Lichtenstein, P., Gillberg, C., & Minnis, H. (2017). Maltreatment‐associated neurodevelopmental disorders: a co‐twin control analysis. Journal of Child Psychology and Psychiatry, 58, 691-701.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Marks J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14, 245-258.

Marryat, L., & Frank, J. (2019).  Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study. BMJ Paediatrics Open, 3:e000340.