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Adverse Childhood ExperiencesACEs and TransformationOctober 2018

IntroductionThe Health and Social Care Academy (theAcademy), a programme of the Health andSocial Care Alliance Scotland, gives a voice tothe experiences and concerns of disabled people,people living with long term conditions andunpaid carers. The programme encourages andsupports innovative approaches that will createsignificant and positive changes in health andsocial care in Scotland.In 2015, the Academy brought people togetherfrom across Scotland to discuss how we cantransform health and social care to make surethat everyone thrives. Five themes emergedfrom these discussions which we call our ‘FiveProvocations’1.One of the Provocations, ‘emphasising humanity’,encourages health and social care systems tovalue the people at the centre of their work.Emphasising humanity recognises that focussingsolely on diagnosis and treatment can divertattention from what truly helps us flourish in ourcommunities and as individuals.This paper explores the research surroundingadverse childhood experiences (ACEs), andScotland’s response to this concept. Developingan informed approach to ACEs has the potentialto radically transform health and social care inScotland. The following pages identify some of thechallenges and opportunities that Scotland willencounter on this journey.1 tions/1

ACEs and Toxic StressAdverse childhood experiences, or ACEs, areharmful events that negatively impact a child’smental, physical, or emotional wellbeing. ACEsinclude childhood experiences of abuse or neglect,as well as exposure to household dysfunction suchas parental imprisonment or domestic abuse.Partly, this increase in risk is due to the greaterlikelihood that as adults they will participate inbehaviours that may impact their health suchas excessive or repeated use of alcohol or otherdrugs. For some, these behaviours becomecoping mechanisms to manage the physical andemotional impact of childhood trauma. In Walesfor example, research found that adults whoexperienced higher levels of adversity in childhoodwere six times more likely to smoke.3 Somestudies have theorised that this increase may bedue to the calming neurological effect of nicotine.4While some level of stress is essential for healthydevelopment, excessive intensity or frequency ofthese harmful events activates a child’s stressresponse too often. Without sufficient supportfrom an adult, prolonged exposure to highlevels of the hormones activated by stress, suchas epinephrine or cortisol, can derail, or evenfundamentally alter, the development of a child’sbrain and body.2.People who don’t engage in behaviour that couldnegatively impact their health still have a greaterchance of developing a range of health conditionsif they experienced childhood adversity. Findingssuggest that this increase in risk is the result ofrepeated exposure to toxic stress in childhood.5Continual exposure to a high level of stress isoften referred to as ‘toxic stress’, in part dueto its hazardous effect on health and the areasof the brain critical for learning and behaviourmanagement.Behavioural and social research suggeststhat higher levels of resilience can be found inchildren who have at least one positive and stablerelationship with an adult. These relationshipscan act as a barrier against the effects of trauma,helping to mitigate its impact on brain and bodydevelopment. Stable and positive relationshipswith adults play an essential role in helpingchildren to develop key skills such as monitoringand regulating behaviour.6Over the last two decades, studies throughout theworld have identified that adults who experienceACEs, and as a result toxic stress, are at a muchgreater risk of developing a range of healthconditions including depression, heart disease,and diabetes.2 E%20&%20Resilience%20Report%20(Eng final2).pdf3 E%20&%20Resilience%20Report%20(Eng final2).pdf4 0017-8/pdf5 ocial-care-inscotland/6 ilience1.pdf2

The First ACE StudyIn the late 1980s, Vincent Felitti, head of KaiserPermanente’s Department of PreventativeMedicine in San Diego7, became concerned thatthe dropout rate of participants at Kaiser’s obesityclinic was approximately 50%. Investigatingfurther, he discovered that many of the peoplehe interviewed who had left the programmehad experienced childhood sexual abuse. Theinterviews indicated to Felitti that these peoplemay be gaining weight because of their childhoodexperiences.8Joining with Robert Anda from the Centers forDisease Control and Prevention (CDC), theysurveyed over 17,000 patients from 1995 to1997 to discover how childhood trauma impactedhealth and wellbeing.This pioneering study examined 10 adversechildhood experiences prevalent in researchliterature and suggested by almost 300 Kaisermembers to be the most common.The 10 ACE Categories from the Kaiser Study:Many of the participants in the first ACE study were white, middle class, college educated, and hadaccess to good quality health care. Even so, over 50% of survey respondents had experienced at leastone ACE during their childhood indicating that ACEs are very common in society.97 Kaiser Permanente is one of America’s leading health care providers. The Kaiser Permanente Centre for Health Researchwas founded in 1964 and performs public health research within large, diverse populations. https://research.kpchr.org/About8 n-obesity-clinic/9 https://acestoohigh.com/aces-101/3

ACEs in ScotlandResearchIn 2016, the Scottish Public Health Network produced ‘Polishing the Diamonds - Addressing AdverseExperiences’10 which summarised the research and set out areas for action in Scotland. This led tothe establishment of a Scottish Multi-disciplinary ACE Hub. The membership of the Hub includesrepresentation from Health, Police, Social Work, Third Sector, academics and the Scottish Government.It is involved in action to: Raise awareness of and understanding about ACEs Contribute to developing the ACE evidence base Explore and share policy and practice approachesto prevent ACEs and mitigate their negativeimpacts. NHS Health Scotland and other members of the ACE Hub have established links with colleagues inPublic Health Wales11, England and in Northern Ireland to share approaches including on research andpolicy and in a variety of settings including primary care, education, police and housing.10 /2016 05 26-ACE-Report-Final-AF.pdf11 ACE focussed work is rapidly progressing in Wales with the first ACE study for Wales occurring in 2015. An ACE SupportHub has been developed by a voluntary collaboration of organisations, including Public Health Wales, called Cymru WellWales. The ACE Support Hub seeks to support individuals and communities to make the changes that will establish Walesas a leader in tackling and preventing ACEs. http://www.wales.nhs.uk/sitesplus/888/page/878354

PolicyThe Scottish Government set out its commitment to preventing and mitigating ACEs within theprogramme for Government 2017-1812. This commitment is focussed on preventing ACEs andsupporting the resilience of children and adults in overcoming early life adversity across all areas ofpublic service. This builds on the Getting it Right For Every Child (GIRFEC) approach13. In March 2018,the Deputy First Minister, John Swinney hosted an ACEs event at Bellahouston Academy attendedby cabinet members including the First Minister14. Following this, the Scottish Government createda dedicated web page for ACEs15 and asked people to continue the national discussion, providecomments and feedback directly to them, or use other networks including social media16. The ScottishGovernment has also published a summary of evidence on links between childhood adversity andcriminality in adulthood17.PracticeNHS Health Scotland launched an animationin May 2018 to provide an insight into ACEs inScotland and how to respond to early adversity18.This can be found along with other relevantinformation on ACEs in Scotland on the NHSHealth Scotland website19.open to anyone with an interest in ACEs and hasover 3,000 members.The documentary ‘Resilience: The Biology ofStress and the Science of Hope’23 follows theprogress in America from the initial discoveriesabout the links between the number of adversechildhood experiences surveyed in an adultpopulation and health. It covers the challengesin generating action to address this public healthdiscovery and how these findings are now beingacted upon across America.NHS Education for Scotland produced a TraumaTraining Framework20 which is aimed at thewhole workforce. The Scottish Governmentwill be investing an additional 1.35 million todevelop a national training strategy to supportits implementation. NHS Education for Scotlandhas also produced an animation which aims toincrease understanding in the workforce abouttrauma21.The film premiered in Glasgow in April 2017 andlaunched a Scottish wide tour of the film led byConnectedBaby24 and ReAttachment25. In 2018,a number of organisations arranged furtherscreenings throughout Scotland, including theALLIANCE and NHS Health Scotland.Alongside the Scottish Multi-disciplinary ACEshub, several regional and national groups havebeen established. The ACEs Scotland Forum22 is12 http://www.gov.scot/Publications/2017/09/846813 tingitright/what-is-girfec14 od-experiences-aces-ministerial-event/15 od-experiences/16 For example, on Twitter using #ScotlandACEs17 hildhood-adversity-resilience-crime/18 w-ofaces#Animation19 hildren/adverse-childhood-experiences20 ogy/nationaltrauma-training-framework.aspx21 https://vimeo.com/27470369322 https://twitter.com/acesscotland23 https://kpjrfilms.co/resilience/24 http://connectedbaby.net/25 http://reattachparenting.co.uk/5

What could make ACEs transformational? Integrate routine ACE inquiry into existinghealthcare assessments. Routine screeningswill provide healthcare professionals with moreopportunities to deliver personalised traumainformed care and support for adults with highACE scores. An ACE informed approach shouldbe used to support and empower healthcareprofessionals to shift the conversation fromone of treatment, “what’s wrong?”, to one ofexperience and wellbeing “what happened?”. The effects of adversity in childhood canreverberate in many areas of adult life. ACEsrequires a cross-sectoral, whole life approachto ensure Scotland’s public bodies can developshared and transparent goals. Only by workingtogether and learning from the experiences ofadults with ACEs can significant and positivechanges occur in health and social care. A national ACE study should be produced inScotland to understand the prevalence of ACEsin Scotland. Furthermore, research and factfinding should be undertaken to evaluate whatworks well in helping to mitigate the impact ofACEs and toxic stress. This information shouldbe used to support greater understandingon how data, resources and services can betransformed to support people who haveexperienced adversity. Increase investment and support for parentsand families to help break the inter-generationalcycle of ACEs. More guidance and support for adults who haveexperienced childhood adversity. Strategies andpractical steps should be readily available forpeople and communities. Recognising that people do not always need orwant a healthcare solution or quick fix regardingACEs. In some circumstances, acknowledgementand appreciation that childhood experiences canaffect later life is of great value. 6