Blackburn with Darwen: ACEs screening pilot
Blackburn with Darwen Borough Council has a strong commitment to integrated early intervention and its early help services focus on prevention and targeted support in order to break the cycle of deprivation and reduce the risk of poor outcomes for children and families. Over the past three years and led by public health the council has been looking at new ways of identifying adults who have experienced multiple childhood trauma and putting support in much earlier with the right families with the aim of preventing the negative cycle of intergenerational problems.
Blackburn with Darwen have adopted the Adverse Childhood Experiences (ACE) assessment developed and robustly tested in the states, which provides an evidenced based assessment of the impact of childhood trauma such as emotional and sexual abuse and physical and emotional neglect.
The US findings indicated that these negative childhood experiences are risk factors for accurately predicting a range of negative outcomes in adult life including poor mental and physical health including binge drinking, unintended teenage pregnancy and drug use.
These factors are the 10 ACEs (graphic):
- sexual abuse before age 18
- emotional abuse by parent/loved one
- physical abuse by parent/loved one
- emotional neglect by parent/loved one
- physical neglect by parent/loved one
- loss/abandonment of or by a parent
- witnessed abuse in the household
- drug/alcohol in the household
- mental illness in the household
- loved one incarcerated.
Compared with people with no ACEs, those with a score of 4 or more were found to be:
- 2 times more likely to currently binge drink and have a poor diet
- 3 times more likely to be a current smoker
- 5 times more likely to have had sex while under 16 years old
- 6 times more likely to have had or caused an unplanned teenage pregnancy
- 7 times more likely to have been involved in violence in the last year
- 11 times more likely to have used heroin/crack or been incarcerated.
In 2014 the English national ACE study interviewed nearly 4,000 people aged 18 to 69 years from across Englandand produced comparable results to the US.
Aim of the work
The ACE studies led Blackburn with Darwen to develop the Routine Enquiry about Adversity in Childhood (REACH) screening tool to enable practitioners to identify adults with high ACE scores who have experienced multiple adverse experiences, which may lead to not only poor health and social outcomes but are also at higher risks of exposing their own children to adverse experiences.
The goal is then to support these individuals and families through targeted parenting programmes and interventions such as Think Family to enable them to provide safe and supported childhoods for their own family.
The long-term aim is to embed this approach across organisational systems and develop a response that focuses support on addressing the long term causes of poor outcomes rather than the presenting symptoms.
What was done
In 2013 the Borough Council worked with Lancashire Care NHS Foundation Trust to pilot REACH training for 100 staff who were part of the early intervention service. Alongside the training there was also organisational support to better understand the risks and challenges of using this approach and the impact on service demand, if it exposed any gaps in service provision and staff training and supervision. For example professionals found using REACH lead to individuals disclosing experiences which they have not discussed despite previous contact with a range of services.
The training has since been expanded to other sectors including health, voluntary and community agencies and more recently the police. There has been a positive response from professionals who have found the systematic and planned discussion a powerful tool in enabling individuals to talk about and disclose very difficult experiences that may have taken place many years before. Partners recognised that without a deeper understanding of the individual’s early experiences then there is the risk of repeating inappropriate interventions that don’t address root causes and will not improve outcomes in the longer term.
Blackburn with Darwen are awaiting the findings of their evaluation of the implementation of the REACH approach, which is due in June 2015 and will consider how to further embed the approach in systems and practice. For example:
- determine who to screen – those at increased risk of 4+ ACEs: Youth Offending; Probation; Troubled Families; young pregnant mothers/families, Paediatrics
- identify interventions for those with high ACEs: targeted Doula initiatives, expanding Early Start Programme, FNP, improved sexual health services
- systematically embed REACH in systems
- enquiring early/responding appropriately: reduce costly interventions that focus on symptoms.
What was the impact?
The English survey reinforced the US ACE study and made a powerful case for investing in early intervention through the REACH approach. By identifying adults and specifically parents in need of additional support then a more integrated, whole system response has been developed across agencies rather than referral to individual services that address single issues.
REACH has helped partners such as health, social care, education and criminal justice become ‘ACE aware’ and they have started to integrate this approach into their long term vision, strategies and training. It has helped to identify gaps in provision for early help, for example in relation to bereavement and loss particularly for children & young people. Despite concerns that there would be an upsurge in demand for higher levels of intervention following disclosure this was not the case.