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What should happen next? Identifying next steps for taking the ACEs evidence forward through a consensus-building exercise


19 Aug 2021

Eighteen months ago, EIF published a major review of the evidence on adverse childhood experiences, or ACEs. Dr Kirsten Asmussen lays out the journey we've been on since then to test where there is widespread agreement on the recommendations of that report, and to gather suggestions on taking ACEs forward in policy and practice.

Today we publish the findings from a consensus-building exercise, conducted with support from RAND Europe, Adverse childhood experiences: Building consensus on what should happen next. This work is particularly innovative and exciting for us, as it is the first time that we have formally considered how our audiences understand and use the evidence described in an EIF report, and gathered their views on how to take this evidence forward in policy and practice.

The new report follows on from our major 2020 review of the evidence on adverse childhood experiences (ACEs). ACEs are traditionally defined as six forms of child maltreatment and four forms of family dysfunction, stemming from a landmark study published in 1997. Our report comprehensively reviewed the controversies that have emerged around the understanding and application of ACEs over the past 20 years, from the perspective of the most robust evidence on childhood adversity. Our analysis confirmed that ACEs are traumatic and can negatively influence children’s development, particularly their mental wellbeing. Nevertheless, we said, there are many things that we still don’t know about ACEs, especially when it comes to predicting their impact on an individual child. While it is clear that ACEs do predict poor adult outcomes at the population level, this knowledge is not sufficient for identifying the individual children who are at the greatest risk.

We concluded our report with a set of nine recommendations about how the ACEs evidence and could be improved, and outlined what an evidence-based public health response to ACEs might look like, through the implementation of 33 interventions with robust evidence of either preventing or stopping ACEs.

These messages received enthusiastic endorsement when we published them 18 months ago, but it was nevertheless clear that some points remained controversial. That is why we decided to conduct a consensus-building exercise to better understand the extent to which our audiences agreed with our recommendations and to gather their ideas for the next steps in taking these recommendations forward.

For this study, we made use of the ‘Delphi’ consensus-building method, which convenes a group of experts and asks them, via a survey, to provide their opinion about a topic in the form of multiple statements. Agreement on these statements is then sought in subsequent survey rounds, where participants are asked to rank their agreement with the anonymised statements of other participants. The end result is a set of statements where the rate of agreement amongst experts is 70% or higher.

70 experts generously gave their time to participate in the three survey rounds of our Delphi exercise. These experts included policymakers, commissioners, researchers, practitioners, representatives from children’s charities, and individuals with lived experience. Participants were strongly enthusiastic about the original report and its messages: 75% said it increased their knowledge and understanding of ACEs and 87% agreed that it had helped them understand, or be aware of, some of the existing gaps in the ACEs evidence. Participants also endorsed all of the 2020 report’s conclusions and recommendations, with each of these receiving 80% agreement or higher by the final round. And in total, by the end of the third round, agreement of 70% or higher was reached on 41 suggestions for next steps in taking the ACEs evidence forward.

Twelve of these statements are what we would describe as ‘evidence-based’, meaning that they are well aligned with the best research evidence. These statements include suggestions for improving the quality of the ACEs evidence, as well as calls for national policies that would explicitly address the structural inequalities known to contribute to ACEs. There was also strong agreement that a comprehensive public health strategy was necessary to stop and prevent child maltreatment, and that this should include support to local areas to put it into practice.

It was also clear that our participants felt that that trauma-informed care and universal ACE screening should undergo further evaluation before they are adopted into widespread use. While we also view these suggestions to be evidence-based, we are now recommending that all universal ACE screening be stopped until a fully validated instrument is available. We make this recommendation in light of new and robust evidence showing that the most commonly used ACE tools are ineffective at identifying the children who are at the greatest risk. There is also growing concern amongst practitioners that many of the ACE screening questions may be causing unintentional harm.

More detail about our panel’s suggestions and their alignment with the evidence base can be found in the main report, alongside a technical annex providing more in-depth analysis of where our audiences agreed with our report and with each other.

About the author

Dr Kirsten Asmussen

Kirsten is head of what works, child development, at EIF.