Lifelong impact of adverse childhood experiences is a message for us all

The heartbreaking scenario of a seven-year-old boy and his nine-year-old sister fending for themselves while their mother was bound and placed in a wardrobe for four days was shared at a recent conference in Dublin.

Family and child psychotherapist Joy Winterbotham told their story, as reported by Kitty Holland in this newspaper, to illustrate how children are being misdiagnosed with personality or behavioural disorders when in fact they are suffering from the effects of trauma.

Awareness about the impact of Adverse Childhood Experiences, Aces for short, is gathering momentum in Ireland. Within the same week of that conference, not only was there another seminar looking at the impact of Aces on brain health – with a focus on homelessness – but also the top prize in the All-Ireland Community and Council Awards went to an organisation spreading the word at grassroots level.

To wonder what happened to someone instead of what’s wrong with them can be a transformative shift in mindset. Not only for healthcare workers, teachers, social workers and policymakers but for anybody who considers themselves capable of compassion.

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The science is there now to show how the toxic stress of adverse events, such as physical, sexual or emotional abuse, neglect and parental separation, can cause biological changes that may have lifelong effects on both physical and mental health. Significantly increased risks of heart disease, stroke, cancer, accidents, suicide attempts and dementia have all been linked to people who have multiple Aces behind them.

Our bodies turn on “fight, flight or freeze” hormones when we perceive danger, useful in the moment but damaging if left switched on for too long. We now know from neuroscience that if a child is on constant alert to a threat – be it from, say, domestic violence, an addict in the household or sexual predator – development of their prefrontal cortex, used for executive function, can be stunted. They can’t learn when their brains are overloaded with stress hormones.

The effects of poverty increase the risks of Aces and their accumulated impact but no level of society is immune.

"This is not about them and us, it is about all of us," says Dr Maeve Hurley of the Cork-based Relationships in Practice (formerly known as Ag Eisteacht and now operating under the Social and Health Education Project in Ballintemple). The organisation was awarded the Grand Prix, as well as gold in the Best Community Health category, at the council awards for its initiative to provide screenings of a critically acclaimed documentary about Aces, Resilience: The Biology of Stress & the Science of Hope, to community-based practitioners in various professions throughout Ireland.

A former GP, Dr Hurley has long believed in the importance of the relationship between healthcare professionals and their patients. In 2001, she co-founded Ag Eisteacht, to promote a relationship-centred approach in frontline practice. At the start of this year, the charity transferred its work to the Social and Health Education Project (SHEP) and Hurley stepped down as chief executive but remains part of the training team.

She hadn’t heard about the concept of Aces and their documented link to destructive behaviours and diseases until she watched the 2016 documentary Resilience among an audience of several hundred at a conference in Belfast.

“It made so much sense,” she says simply. There was no sensationalising of the message, which was all the more powerful for the sensitivity of its delivery. Having heard that some of those watching with her in the conference hall had been personally quite upset, she resolved that not only did she want as many frontline professionals as possible to see this film, but also that they should do so in small groups with a chance to reflect and discuss afterwards.

“I think people need a safe, supportive environment to view this – because it is about all of us,” she repeats. “You don’t know if the person sitting beside you might have had seven Aces.”

The film not only raises awareness of Aces, but also demonstrates how supportive relationships can “buffer” the negative effects of adversity. “No matter how troubled somebody is and how they have been impacted physically, mentally, emotionally by adversity, there’s always hope,” she says. “The brain is neuroplastic; we have capacity for repair.”

This offers hope not only to an individual, but also to professionals who may feel ground down by despair at seemingly unbreakable generational cycles when working with children and families from troubled backgrounds. The message to them is “that the relationship you have with that person can make a difference”.

A landmark public health study published in the US in 1998 was the first large-scale research to link childhood stressors and household dysfunction to a dramatic increased risk of many of the leading causes of premature deaths in adults. The study was conducted after two doctors in very different fields had come to similar conclusions about childhood trauma.

Working in a Californian obesity clinic, Dr Vincent Felitti was puzzled why half of his patients dropped out of his programme despite losing weight. Through digging deeper into their medical records and then conducting face-to-face interviews with nearly 300 of those who had stopped coming to the clinic, he and his colleagues were astonished to discover that most had suffered child sexual abuse. For them, over eating had become a solution, both as a comfort and a means to being "invisible", and reducing their body size had threatened that "fix".

Felitti collaborated with Dr Robert Anda, who had been exploring how depression and feelings of hopelessness affect heart disease, to set up that first Ace study with almost 17,500 participants. They were surveyed on 10 adverse childhood experiences – sexual, verbal and physical abuse, emotional and physical neglect, a parent who's mentally ill or alcoholic, a mother who's a domestic violence victim, a family member who's been jailed, and a loss of a parent through divorce or abandonment. But clearly that is not an exhaustive list.

The resulting data enabled researchers to track the effect of one or more Aces in later life. It found those with four or more had startling consistent higher rates of health, emotional and social issues. This makes a compelling argument for early interventions, both to reduce the incidence of adverse events and to lessen their toxic effect.

Traditionally, we might have put children’s problems down to parents not doing a good enough job, says social care consultant Dr Nicola O’Sullivan. “Now we know that parenting is very, very difficult and we bring our own experiences of being parented even when we don’t want to.”

In even the most “normal” households, people find themselves saying things to their children that their parents said to them, even though they might have sworn they never would do that. “We have to be very careful not to blame parents. If a parent doesn’t have money, or can’t get a bus to an appointment, that parent is going to be more stressed. It is a societal issue. If we locate the problem in the parent, we relieve ourselves of any responsibility,” she says.

Toxic stress is when there is no relief to be found. That's when it becomes very difficult, especially for a child who has to rely on themselves and that's frightening

Long before the Ace movement, it was known that trauma is transmitted across families. O'Sullivan cites a 1975 paper, entitled Ghosts in the Nursery, in which Selma Fraiberg "talks powerfully about the mother and babies she works with in the community and says sometimes when you're in the room with the baby, there are two babies crying, the mother and the baby. You have to hear the mother's cry before the mother can hear the baby's cry."

O'Sullivan, who has worked with Relationships in Practice to facilitate screenings of Resilience, says it is not just a matter of sending people off with this information about Aces, it is an invitation to think about it and debate it.

There is a risk that people would use Ace criteria to screen everybody and that is not what is recommended. It is a research tool, not a clinical diagnostic tool. If we start to score people, it is back to locating the problem in the person rather than the environment, she argues.

First 5, the Government’s strategy to improve the lives of babies, young children and their families, along with the work of the Infant Mental Health Network, are examples of early intervention measures to avert Aces, “but like anything, we have to do more”.

The very hopeful message from Ace awareness for any frontline professionals is the role that they can play in mitigating the effects. People can experience a lot of stress and trauma but if they find support within close relationships, that eases the pressure and helps them to cope.

“Toxic stress is when there is no relief to be found,” O’Sullivan explains. “That’s when it becomes very difficult, especially for a child who has to rely on themselves and that’s frightening.”

Those working with children need to regard every interaction as an opportunity to make a difference. “Imagine,” she adds, “being a child navigating through your day if everybody responded to you with that thought.”

Read: School adopts a ‘curious instead of furious’ outlook