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Off to hell in a hand cart? Challenging a simplistic view of ACEs and their impact


26 Feb 2020

Isabelle Trowler, chief children's social worker for England, responds to EIF's major new evidence review on ACEs, and questions the notion that adverse childhood experiences should be taken as fixed determinants of future outcomes.

Is it really possible to pre-determine what happens to you in your adult life because of what happened to you as a child? Every bone in my body screeches no, no, no ... no it is not possible, and nor is it a desirable aspiration. Many know I have been a harsh critic of early intervention: its tone of inevitable escalation rankles, and many local services are rarely sophisticated enough to meet the complexity of the social needs facing many families. More recently, I’ve been rolling my eyes a lot over the seemingly unstoppable professional march of the adverse childhood experiences narrative and the deterministic nature of much of its rhetoric. ACEs: it seems like you either love ’em or you hate ’em.

So you might think that the Early Intervention Foundation and I are strange bedfellows. Not so. In recent years, I have really welcomed their much more nuanced approach to how public services should be designed and delivered. We both agree that there is an evidence base that is often not well understood or used, that the knowledge and skills of practitioners working with families are not sufficiently well developed, and that the national dialogue about how best to help families can sometimes lack perspective and depth.

EIF’s latest report – Adverse childhood experiences: What we know, what we don’t know, and what should happen next – has really made me sit up and take note, and I thank them for it. On a first read of something new, we tend to key into the messages that support our world view. So, their headlines – that the excitement from the ACEs movement should be tempered with a dose of reality about the strength of the evidence base, that there are no quick fixes to prevent adversity, that we don’t know enough about the impact of screening on children, and that in any event it is unlikely to be a substitute for empathic conversation – are very welcome indeed. The acknowledgment that other adversities in childhood – for example, caused by poverty – need a greater profile has enabled me to go on reading.

The report also challenges my biggest bugbear: the deterministic nature of some of the ACE rhetoric in use. On this, the authors state (emphasis theirs): ‘It is clear that high levels of adverse experiences occurring in childhood significantly increase the chances of a number of negative outcomes in adulthood. However, it is important to note that the absolute size of many of these risks remains relatively small.’ They use a great example to illustrate this. Experiencing four or more ACEs increases the odds of intravenous heroin use by ten-fold. Now, that sounds like something we should all take seriously: you can see the headlines now. But we need to dig deeper. Actually, the underpinning study showed that 0.3% of those with a history of no ACES went on to use heroin, compared to 3.5% of those with four or more ACEs. So, 96.5% of those who had experienced 4 or more ACEs did not use heroin intravenously, at all.

Bingo! While ACEs have an important role to play in raising general awareness of the impact of, for example, child abuse, or developing public health strategies for whole populations, we need to be really, really cautious about linking individuals to pre-determined destinies. It is just not ok to do that. While I assume everyone promoting ACEs would vehemently oppose any suggestion that that is their intention, the mood music being created suggests something else. For example, some of the promotional material I have seen, which is made to be accessible to children, I have found deeply disturbing. As an adult with a few ACEs, I would surely conclude I was off to hell in a handcart. If I was a child, I suspect I would be terrified. As the EIF report makes clear, very little of this activity has been tested and so we need to be sure we aren’t causing harm, however well-intentioned these interventions may be.

In their report, EIF is offering something much more than a critique of ACEs. It is offering a way forward. It is definitely not saying that ACEs do not have value – in fact, it is saying the opposite. But it is also saying we need to understand the full value of ACEs and their application, before we go policy wild! I hope this report might build a bridge between those on either side of the debate. The push for a whole-system, public health approach – one which moves us beyond the 10 ACEs and acknowledges the impact of socioeconomic disadvantage – should be of interest to everyone. I love the focus on the need for highly skilled practitioners, and the push away from screening and towards offering effective helping strategies. EIF is planning further work off the back of this report to work through its implications with some of the different sectors and workforces to whom it is relevant. I really welcome this. I still have lots of questions and look forward to the debates that this publication should trigger.

Do read it, and join in.