Child Trauma-A Global Policy Agenda.

Parenting, education & environment in childhood drive wellbeing in adulthood everywhere.  Adverse Childhood Experiences (ACEs) including 1o different types of neglect, violence and dysfunctional parenting in the home during childhood, harm the economic, social & democratic development of any society.^[1]

Recently global development collaboration efforts have expanded beyond the visible challenges of disease, hunger & illiteracy to also tackle the less visible emotional, social & psychological barriers to human development. The current UN sustainable development goals call for an end to all forms of violence in the lives of children everywhere by 2030.

Adverse Childhood Experiences (ACEs) are much more prevalent than policy makers previously imagined and are distributed within a similar range across continents, classes and races. They include emotional, physical or sexual abuse, emotional or physical neglect & chaos at home including domestic violence, mental health, addiction & crime .

There are ACE or similar Violence Against Children (VAC) surveys from at least 33 countries and 32 US States. These included the UK^[2],, Canada^[3], China^[4], Russia^[5], Brazil^[6], Poland ^[7]and countries in Africa^[8]and Asia^[9]  [10]. 

Looking at the data from 11 European, 12 African, 6 Asian, the US, Brazil and Canada (the 1^st, 2^ndand 5^thmost populous countries of the Americas)  and the Solomon Islands, the first thing that is striking is the similarity in prevalence of ACEs. On average about 60% of adult populations have experienced 1 ACE. Some countries such as Brazil and Russia are closer to 80% and some such as the Wales and Serbia are closer to 50%. But almost all countries fall somewhere between 50 and 80%, most hovering around the 60% mark, Similarly the prevalence of 4 or more ACEs is on average around 15%, though some countries have less than 10% such as the Czech Republic and some have more than 20% such as Vietnam. 

This is a relatively new form of research and relying on subjective responses to a questionnaire. ACE research  in the US shows little difference in prevalence of 1 ACE in social class or ethnic groups. However, a link between prevalence and poverty is clear when it comes to 4 or more ACEs.^[11]

When we think about violence against children in the family often the first policy intervention we think of is a targeted social work response. But lets think again. . In a country like Wales, the prevalence rate for 1 ACE is 50%, the prevalence rate for 4 ACEs is 14%, yet the total number of children who are subject to targeted social work intervention for example on a register or in care, it is 1%^[12]. To achieve the UN global target to end violence-we need to massively expand universal efforts through prevention & mitigation through health, education and policing working alongside social work.

There is no one reading this blog whose life is not affected by ACEs in some way. ACEs don’t just affect individuals, they affect societies

We know this because where ACE studies have been undertaken they always show a dose response correlation between the number of ACEs you have experienced and poor outcomes in almost every single wellbeing indicator in health, education, crime violence, mental health, addiction and much much more. throughout the entire life cycle

Perhaps the starkest illustration of the inter-generational transmission of violence, criminality and addiction is in the graph below from a 2015 study from Public Health Wales in collaboration with Liverpool John Moores University highlighted a high correlation between adults who experiences four or more ACEs and negative life outcomes^[14]:

Compared with people with no ACEs, those with 4+ ACEs are:

4 times more likely to be a high-risk drinker

6 times more likely to have had or caused unintended teenage pregnancy

6 times more likely to smoke e-cigarettes or tobacco

6 times more likely to have had sex under the age of 16 years

11 times more likely to have smoked cannabis

14 times more likely to have been a victim of violence over the last 12 months

15 times more likely to have committed violence against another person in the last 12 months

16 times more likely to have used crack cocaine or heroin

20 times more likely to have been incarcerated at any point in their lifetime

The Wales data also show a much higher likelihood of becoming a victim of violence if you have higher ACEs. Recent work in England has revealed that grooming gangs have a tendency to go after young women with low self-esteem and what psychologists call “ambivalent attachment” as an outcome of inconsistent, neglectful and chaotic parenting in childhood.

The Welsh data is similar to what we see across societies globally. Health departments across US states reveal a similar dose-response correlation between higher aces and worse outcomes in health, wellbeing and decision making with regard to 40 different indicators^[15]. The indicators include health outcomes but also behaviours related to addiction, criminality, mental health and unemployment.

Research from China shows a similarly graded link between ACEs and likelihood of alcohol abuse.^[16]While ACE studies from Malawi^[17] and the Solomon Islands ^[18]showed a similar graded link between risky behaviours, such as multiple sexual partners and high ACE scores.

Psychiatric evaluations of 1000 detainees at Cook County Juvenile Detention facility in Illinois revealed that 84% of offenders had experienced two or more ACEs and that the majority of offenders had experienced 6 forms of childhood trauma. ^[19]In a recent study in North Macedonia on ISIS recruitment all teachers, without exception, cited lack of parental care as a major factor for driving children toward radical extremism.^[20]

Amongst children in school, if we take ACE data from WHO across Eastern and Central Europe and OECD data from the Pisa study, there is evidence of a correlation between higher than average ACEs and higher rates of school violence^[21]. Coupled with the data from Wales showing a link between high ACEs and criminal and violent behaviour, this adds to a growing body of research showing the clear link between family and societal violence and criminal behaviour.

The American Academy of Paediatrics (AAP) suggest that periods of prolonged stress without respite in the home result in “toxic stress” or chronic activation of the stress response system^[22]. Research shows that it is not just violence and chaos that creates toxic stress but also emotional coldness from the parent. This is because children are biologically programmed to seek strong bonds and attachments from birth for love and stimulation, but also for protection. As a species we are extremely dependent on parents for protection in early childhood. When the emotional attachment is absent, children see it is a threat and it activates the stress response system. This was also a finding of the prior research on attachment in psychology which revealed that while neglected children often stop showing outward signs of emotional need, their heart rate and cortisol levels are high ^[23]

Toxic stress derails normal development of all major systems of the fragile and evolving body and brain of the child. The impact affects the neurological, cardiovascular, immune and endocrinology systems and the way that genes are expressed. One of the impacts of toxic stress is that the body and brained is flooded with the stress hormone cortisol. Research showed that children who had been adopted in Canada but had spent their first year in a state of extreme neglect in children’s homes eastern Europe had much higher levels of cortisol than those who had been adopted earlier or who lived with their biological parents. This despite the fact that the high-cortisol children had spent most of their life in a secure adopted family.

Toxic stress also over-activates the amygdala region of the brain and the human fight or flight response and de-activates the executive function, impulse control and learning capacity of the brain. Children with high ACEs are likely to have problems with concentration, self-soothing and remaining calm and concentrated in the classroom. They are also likely to over-estimate the presence of danger and therefore are more prone to over react and make poor choices in the face of challenges such as perceived “disrespect” from peers or even adults.

This is particularly true during adolescent brain development-when personality and values begin to take shape and underpin individual identity, but also when there is a mismatch between mature impulse response and immature impulse control systems. All of this leads to poorer education outcomes and higher likelihood of

The UK Police are increasingly using ACEs to understand and prevent criminal behaviour such as drugs trafficking across country lines or urban knife crime.^[24]It is widely assessed that criminal gangs or violent radical organisations on the one hand, and organised groomers and human-traffickers on the other-prey on young people from high ACE backgrounds. Knowing that there is a neurobiological pathway for high propensity for being a perpetrator or victim of violent crime has led to new levels of collaboration across police, health, social work and education sectors.

Some of the solutions to child trauma, adversity & violence are now known

The first is primary prevention.   Nursing visiting where the nurse can demonstrate secure attachment behaviours and positive parenting strategies can halt intergenerational transmission at the moment when the relationship and the parenting style if being formed. The importance of the parent practising the behaviours with the support and guidance of the nurse is crucial. Often for new parents with high ACEs , for example for young women from state care backgrounds,  having children in a supportive environment is the breakthrough which enables the parent to strengthen their attachment capability, self-soothe and overcome their own high ACEs background.  This is important because the first step to preventing intergenerational transmission of ACEs is ensuring that the parent is okay, calm and without anxiety Through longitudinal studies in Jamaica and the United States, Nobel prize winning economist Professor James Heckman demonstrated improved productivity, more health-seeking behaviour and reduced criminality amongst young adults who had received home visits decades earlier as babies yielded up to a $ 17 return for every public dollar invested, and that this was the biggest return on public investment that any government can make. ^[26] This correlates with research done by the Overseas Development Institute which conservatively suggests that 8% of global GDP is lost through the long term costs of violence against children.^[27]

The World Bank, UNICEF & WHO now cite the Heckman research  to advocate for  governments to create fiscal space for investment in perinatal care, parenting and also pre-school for three to six year olds. The pre-school component is also important in combatting ACEs because the absence of stimulation and presence of toxic stress at home in early childhood derails language acquisition and other key learning and concentration attributes which cannot be caught up later and further diminish the prospects of progressing through school thus exacerbating the negative impact of ACEs on human flourishing. Universal pre-school is crucial to mitigate the long-term impacts of ACEs.

The second policy intervention is building resilience. Studies from child survivors of the holocaust to present-day conflicts and ACE-based research has pinpointed resilience as the main antidote to toxic stress or chronic trauma^[28]. Resilience in childhood is about having “development assets which mitigate the impact of toxic on the brain and body. While the 2015 Welsh study had a dose response correlation between ACEs and poor life outcomes, it also had a dose response correlation of children with ACEs “bouncing back” from trauma if development assets were in place.^[29]

There are many environmental factors, a lot of research of childhood survivors from the holocaust for example pinpoints ability to form and maintain relationships as a key determinant. Having at least one positive relationship is perhaps the one determinant of resilience across all research^[30]. Other key aspects of resilience are things like belonging, purpose and a capacity to self-soothe. It has often been noted that children in state care or other high ACE situations are more likely to do better in life if they engage in sports. There are generations of bar stool pundits who have suggested that this is because such young people have had a chance to “channel their aggression positively” however through the research on resilience we probably now know that the positive correlation with sports and overcoming adversity is rather about positive relationships, belonging and purpose. Another myth that the resilience research bursts is the concept of the resilient individual overcoming adversity through sheer, individual perseverance. In reality where resilience occurs, it is normally because of relationships, not the rugged individual operating by themselves.

A good policy target for governments wishing to promote human flourishing would be to ensure that every child has at least one positive relationship with an adult in their lives. Sometimes this may need to be a teacher, a sports coach or social worker if the family is not able to provide such a relationship. The approach of trauma informed schools in which children are able to regulate, relate & reason…in order words calm down the stress response system, have a deep connection with a teacher and then begin to learn…are increasing being mainstreamed in education sector reform.

For the first time in history, the sustainable development goals provide policy space to make parenting, resilience and violence prevention systems available globally by 2030. To maximise this opportunity, we need to build a global movement that can harness this knowledge into action everywhere and create common understanding across societies whilst maintaining the flexibility to graft these interventions on to local cultures and value systems. Through this approach we can create a world in which all children can have the optimum opportunity to grow free from trauma and thrive in societies which flourish.

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^[1]https://www.cdc.gov/violenceprevention/acestudy/index.html

^[2]http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf

^[3]https://www.albertafamilywellness.org/what-we-know/aces

^[4]http://www.academia.edu/24121998/Association_Between_Adverse_Childhood_Experiences_ACEs_and_Preterm_Birth_a_Case_Control_Study_in_Chongqing_China

^[5]http://www.euro.who.int/en/countries/russian-federation/publications/survey-on-the-prevalence-of-adverse-childhood-experiences-among-young-people-in-the-russian-federation

^[6]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710615/

^[7]http://www.euro.who.int/en/countries/poland/publications/survey-of-adverse-childhood-experiences-and-associated-health-harming-behaviours-among-polish-students-2018

^[8]https://www.togetherforgirls.org/violence-children-surveys/

^[9]https://www.cdc.gov/violenceprevention/childabuseandneglect/vacs/reports.html

^[10]https://www.ncbi.nlm.nih.gov/pubmed/20888640

^[11]  Gilbert et al. 2010 Childhood Adversity and Adult Chronic Disease: An Update from Ten States and the District of Columbia. American Journal of Preventative Medicine. 48(3): 345-349

^[12]http://www2.nphs.wales.nhs.uk:8080/PubHObservatoryProjDocs.nsf/3653c00e7bb6259d80256f27004900db/fc57159cf0046a8a80257c28004aa6ea/$FILE/Children%20and%20YP%20Profile%20Wales%20report%20-%20low%20res%20(Eng).pdf

^[13]https://press.princeton.edu/titles/9434.html

^[14]http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf

^[15]https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

^[16]https://www.sciencedirect.com/science/article/pii/S0895398808600628

^[17]https://www.researchgate.net/publication/325043095_Adverse_Childhood_Experiences_and_HIV_Sexual_Risk-Taking_Behaviors_Among_Young_Adults_in_Malawi

^[18]https://www.researchgate.net/publication/327165969_Adverse_Childhood_Experiences_Mental_Health_and_Risk_Behaviors_Among_Men_in_the_Solomon_Islands

^[19]Karen M./ Abram et al North Western University Post Traumatic Stress Disorder in Youth in Juvenile Detention Archives of general Psychiatry 61 April 2004

^[20]http://www.analyticamk.org/images/2018/CVE-EN-FINAL-WEB_272e4.pdf

^[21]Combining data from https://www.oecd.org/pisa/PISA-2015-Results-Students-Well-being-Volume-III-Overview.pdfand https://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/en/. The latter was compiled by the author for this paper

^[22]https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/ACEs-and-Toxic-Stress.aspx

^[23]http://alfredadler.edu/sites/default/files/Graham%20MP%202015.pdf

^[24]https://www.standard.co.uk/news/crime/looking-behind-the-crime-isn-t-soft-it-s-intelligent-policing-a3966601.html

^[25]  Expanding Circle Peter Singer 2011 Ethics, Evolution and Moral progress Princeton University press

^[26]https://heckmanequation.org/resource/the-heckman-curve/

^[27]https://www.childfund.org/uploadedFiles/public_site/media/ODI%20Report%20%20The%20cost%20and%20economic%20impact%20of%20violence%20against%20children.pdf

^[28]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956753/

^[29]http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20FINAL%20(E).pdf

^[30]https://www.apa.org/helpcenter/road-resilience.aspx

^[31]https://uobschool.org.uk/wp-content/uploads/2017/08/Framework-for-Character-Education-2017-Jubilee-Centre.pdf