“How can I help my child to be self confident when I do not feel self confident myself ?” This is not an intimate conversation between friends. It is not a soul-searching parent in private counselling with a psychologist. It is one of many written questions delivered by a 400 strong audience to the stage of a provincial theatre in North Macedonia. Following dance and comedy, the audience engage with an expert panel on hirtherto taboo themes such as neglect & violence. And you can hear a pin drop.
As with most middle and low income countries, there is little public discussion on childhood adversity. Policy makers rarely prioritise investment to address its lifelong impact and costs. The “Parenting Is Always Learned” campaign has two aims. The first is to introduce the science of brain development to ordinary parents in ordinary places in simple language. The second is to break taboos on family crisis and Adverse Childhood Experiences.
We asked Sasko Kocev, a comedian and actor to moderate the event. We were amazed to the extent this created a conducive environment for discussing a taboo and difficult theme in a non-judgemental way.
It made sense later when we read research in the Power Of Moments by behavioural scientists Chip and Dan Heath. It suggests that laughter creates social bonds and synchronises audience engagement . We are all affected by Adverse Childhood Experiences. Most people have experienced them in their own childhood. Those who haven’t are likely to have their lives entwined with someone who has. Violence and neglect are not a “Them” problem, they are an “Us” problem. Comedy reminds us of our imperfections, at the very least, that we are all a bit broken.
A young dance troupe perform a powerful representation of themes such as alienation and domestic violence. The second half of the event is an interaction between the experts & the audience using anonymous questions.
Adverse Childhood Experiences are as present in North Macedonia as they are anywhere. A World health Organisation supported survey found that 64% of young adults had one adverse trauma in childhood and almost 1 in 10 had four or more. The most common was emotional neglect at 30%. I once asked the entire psychology faculty second grade if the data surprised them. It did not.
A campaign alone will not work. Parenting Is also Learned accompanies reforms of health, education and social protection systems. This includes home nursing visits that promote nurturing caregiving and universal pre-school education.
Often childhood trauma such as emotional neglect is transmitted from generation to generation. It is difficult to talk about neglect as we often have to examine our own behaviour or that of our parents. By acknowledging adversity is often transmitted unintentionally, we can discuss it without judgement. This is essential for breaking taboos and enabling consolidated action on childhood adversity.
The answer to the question posed at the beginning of the article is not easy. How do parents ensure they don’t transmit poor attachment, insecurity or anxiety on to their own children.” But senior British psychologist Peter Fonagy researched the way that being “reflective” prevents such transmission. The more parents become aware and reflective of their own feelings and the way they may impact others, the less likely they are to transmit negative models of care.
And as the name of the campaign suggests, we can learn parenting skills. As the curtains go down and we exit the stage there is a queue of parents and young people seeking to share their experience and ideas. Its 10pm, we have gone on for an hour longer than expected, yet many people don’t want to leave.
As Victor Hugo said, there is nothing more powerful than an idea whose time has come. The idea whose time has come is that we can nurture the first generation to grow without violence and neglect.
I wouldn’t need a large abacus to count the number of times my experience as someone raised in care of the state has been well represented in a film. One fleeting moment in Robert Altman’s 2001 murder mystery Gosford Park, an elegant pre-cursor to Dowton Abbey, nailed it.
During a large and free-flowing dinner table conversation about family, Mr Stockbridge (played by Clive Owen) stunned fellow diners when he answered a question with a simple “because I grew up in an orphanage“. The ensuing silence told more of our story than any scripted dialogue ever could.
Anyone from state care made to describe their background following a routine question about childhood in a polite conversation knows that silence. Until recently and in middle age I still grimaced when such discussions arose at the diplomatic functions I attend with my job. If I am honest about it, at different stages of my life I have felt intrinsic shame, stigma and especially guilt for the discomfort it may cause to others, and this has often fed into a deep, internal narrative that I am not really good enough to be here. On the other hand, I felt compelled never to hide who I am or where I come from. Being from state care is as important for my identity as being a Belgan or being a Hindu may be to someone else. It is where I spent my formative years, it shaped me, and I want to be a good role model for kids in care today. It is at my core. I just would rather not talk about it.
6% of UK 18 year olds from state care go to university compared to around 27% of the general population. When I was 18 (a very long time ago) it felt more like 0%. We were from a minority more likely than any other to end up in prison, a gang, trafficked, addicted or die early and less likely to go to university than any other group in society. Unlike other marginalised minorities, we had no underpinning culture, flags or narrative to foster pride in our identity. I am so proud of the 6% of 18-year-olds from care who attend university today. It is a testimony to resilience, the odds are stacked against them, they make it through anyway.
Like many of my generation, I left a children’s home aged 16 with a €200 leaving care allowance, a modest bag of life possessions and a complete absence of any form of love or belonging at all.
I have never complained about where I come from. This was the way my life was, it was normal to me. Coming from the bottom 1% of a society where identity was shaped by class and family, and then trying to advance though university & career etc often left me feeling unsteady on my feet, like an outsider or an imposter. I still feel like an outsider today to be honest, but I wouldn’t want to go back and change anything.
There are also things I am proud of. Without parental support, generational wealth or any safe place to return I had to work harder than most to get through university. I woke up at 4 am on weekends, when the other students were coming back from parties, to run a market stall in Camden Town. I drove a mini-cab around London late at night and did shifts in an old people’s home and a college kitchen to pay my way through university. I believed completing a university education would help me escape the legacy of my childhood and would do anything to reach that goal. I remember going to my first day of university, buying my own pens and books with money I had earned. I couldn’t quite believe how lucky I was just to be there. It seemed that most took it all for granted. How much luckier I was to see university as a massive blessing. I still feel blessed and privileged today.
What about love? in state care, one often grows up with this internalised sense of being un-loveable, not even by one’s parents. Biologically all children are programmed to seek loving protection and nurture from parents, when it is absent they interpret it as danger. Those from care backgrounds often have low self-esteem, insecure attachment, post-traumatic stress and over-active fight or flight systems. This has a profound impact on your identity and sense of self.
You can strive to be a success on the outside as a young care leaver, inside there are all these jagged edges and broken parts that, if you are aware of them, you would like to put together again. But when you are trying to escape severe poverty without any support networks, you are just thinking about survival. Profound emotional insecurity can be a barrier to the relationships that the research now tells us are the single most important determinant of both healing from trauma and building the resilience to overcome barriers and get on in life. Often the strategy the subconscious gives us is to separate the left and the right side of the brain-to run on the gas of the cognitive: job and education and forget the oil of love, emotion and belonging. Just like a car, you will break down in the end.
Nobody politically can articulate this. The main political discourses in our society don’t do emotional. They only do economic and power.
The left often argues that a care leaver is a victim of discrimination and poverty. As Nimco Ali wrote recently about race & gender & being a refugee “The left wants to frame my life experience via the prism of helplessness and victimhood. I am meant to be consumed by all that has happened to me — to long for all that I have lost and wait to be rescued, but I have always refused to do that“. For me, it has taken me most of my adult life to feel really comfortable talking about being from care. I can be shut down in a moment if someone tries to frame my narrative as a victim, and that often comes from the left.
Economic models from the right squeeze and further disadvantage marginalised care leavers. I know this from the rock face because I left care during Thatcherism. They argue that if an individual care leaver (actually a tiny fraction) can progress through hard work, then anyone can. Evidently they cannot, and do not because the impact of trauma and neglect is very individual and complex and based upon the interaction of experience, resilience & biology. In 2019, policy makers should really know this, we shouldn’t have to explain it. And anyway, as Colin Powell once said, “how can you ask someone to pull themselves up by the bootstraps when they don’t have boots“. Care leavers badly need support networks.
Discrimination, poverty and hard work are high stakes challenges for any care leaver. The main issue remains love, or the lack of it. There is a broader need for a politics that can talk about love, wellbeing, trauma, violence and hope. The social and emotional drivers of all of our behaviour and decisions. And this makes democratic sense because care leavers are not alone.
Until recently there was a common public perception that childhood trauma, neglect & violence were marginal issues addressed through the care, social work and juvenile justice systems dealing with maybe 1 or 2 % of a given child population. The World Health Organisation and other bodies have undertaken surveys in multiple countries on general populations which reveal that on average, around 60% of adults were affected be one serious adverse childhood experience (ACEs) and around 15% by 4 or more. The 15% with 4 or more ACEs, like care leavers are much more likely to have really bad life outcomes in health, crime, education and all aspects of wellbeing. In attachment research, around a third of adults across countries are said to have insecure attachment due to absence or inconsistency of parental love, particularly in the first two years of life. Insecure attachment severely affects their ability to have quality relationships. The common perception about the marginality of trauma runs counter to people’s lived experience and their ability to articulate it. It had always been hidden in plain sight by shame, taboo and myth. That is now changing.
I was raised in care of the state. I am neither proud of it or ashamed of it. I would like to live in a world where future care leavers don’t suffer long silences & superficial victim or bootstraps narratives. Where investments are made to ensure those from public care & others affected by adversity everywhere-can reconnect, build and heal free from shame and public stigma. This would be socially just, fiscally prudent and frankly just plain easier and better for the whole of society.
Even the most hard-nosed economist will now concede investment in good early childhood has the biggest return on public investment.
But what about a reverse argument that failure to invest in prevention of bad early childhood experience is the most costly oversight a government can make?
This is the subject of my recent TedX talk in Podgorica, Montenegro, on the global prevalence of Adverse Childhood Experiences (ACEs) like neglect, abuse and dysfunctional parenting, and how they drive poor public health, low productivity and other costs amongst adult populations.
Despite massive advances in addressing childhood adversity in many high-income countries – globally the issue remains largely taboo, difficult to discuss and emotive. But the field of childhood adversity has been revolutionized through the study of ACEs – here is how it began…
A couple of decades ago in San Diego, public health practitioners baffled by constant patient drop out from obesity programmes decided to probe whether there were any shared underlying factors among those affected. They were astonished to find out that those who dropped out almost all had one thing in common: sexual abuse in childhood.
This begged the question – were there other areas of poor health in adulthood or social outcomes where the people affected had largely been victims of childhood adversity?
What followed in the mid-90s was a longitudinal Adverse Childhood Experiences Study, of more than 17,000-mostly middle-aged and middle-class West-coasters in the US, through a collaboration of Kaiser Permanente clinics and the Centre for Disease Control in Atlanta.
Firstly, the findings revealed the shocking and heart-breaking prevalence of 10 classified types of Adverse Childhood Experiences which were broken down into three areas: 1) Abuse: Sexual, physical, emotional; 2) Neglect: Failure to meet basic physical needs, leaving a child uncared for, or unloved; 3) Household dysfunction: Witnessing, addiction, crime, parent-to-parent violence, mental illness etc.
Respondents were given an “Ace Score” of 1 to 10. Two-thirds of respondents had experienced at least one ACE and 12% of respondents had an Ace Score of 4 or more.
20% had been victims of child sex abuse – a number almost identical to the much later Council of Europe estimate that 1 in 5 European children suffer from sexual violence.
The statistics on all forms of violence also broadly correlate with prevalence levels that can be seen from the global UNICEF report on violence against children: Hidden in Plain Sight.
If researchers were knocked sideways by the shockingly high levels of prevalence, including in middle- and high-income households, they were also astounded to find an almost “dose-response” correlation with high adversity and poor life outcomes, in health, education, addiction and crime throughout the lifecycle.
According to a leading ACE researcher and public health practitioner, Dr Nadine Burke Harris, in California somebody who had experienced 7 of 10 forms of childhood adversity has a 20-year shorter life-expectancy than someone who has experienced none.
It took a different type of research, from the field of neurobiology, to explain why high childhood adversity converted to poor outcomes in adulthood – through the impact of what the Harvard University Centre for the Developing Child has termed ‘Toxic Stress’ upon the physical and brain development of children.
As devastating as all of this is, we now have the knowledge and the science to build a global effort to reduce the impact of childhood adversity and violence against children. If we can reduce the dose of adversity and toxic stress we are not only fulfilling our human rights obligation to protect children, but also potentially ensuring long-term reductions in poor public health, low productivity, high crime etc.
UNICEF works throughout the CEE/CIS region in Regional Knowledge Leadership areas to help governments to simultaneously do three things: 1) Build violence prevention mechanisms, from pre-natal visits and throughout a child’s life cycle; 2) Provide interlocking services of child protection, health, education and justice that will protect the child victim of adversity and help him or her recover; and 3) Break the public taboo on childhood adversity which prevails in almost all of the countries in our region.
In Montenegro in late 2013 we had the first national discussion on child sex abuse as part of a national survey on violence against children in parliament. Services are being strengthened, reporting seems to be on the increase and there is more public discussion. But we are mindful that this is just the beginning.
This way of approaching adverse childhood experiences is flowing from high-income countries where it is studied and researched, to middle income countries where there is some type of functional child protection system. However, according to Theresa Betancourt of the Harvard Centre on the Developing Child there is an obvious need to better understand and work on childhood adversity, mental health and toxic stress in low-income countries or conflict zones, where HIV/AIDS or the recruitment of children into armed conflict, can have a deep psychological and physiological impact on children’s wellbeing.
Courtesy of the wonderful fostering promotion group ReMoved, my TedX featured the story of a resilient, fictional young girl with an Ace score of 6 called Maja. She could be any child-in any corner of the world. Frightened of her own father, uncertain of when she may reach safety or if she will ever be properly loved and cared for.
We can make a massive difference in the life of Maja and millions of children like her by attacking childhood adversity, making the invisible visible and creating a world truly fit for children.
Benjamin Perks is the UNICEF Representative in Montenegro
For most mothers, the first embrace and skin-on-skin contact with her newborn, moments after delivery, is one of the most precious and magical moments in the journey of parenthood. But sometimes, perhaps because of family breakdown, addiction or perceptions about a disability, a mother turns away from her baby and abandons him or her at birth.
And so begins the worst possible life-start for many of the 1.3 million children who reside in the care of the state across Central Asia and Central & Eastern Europe.
In those fragile early days of life, the pathway to state care is lonely and brutal. The child will often be taken from the maternity ward to a large-scale state residential institution adorned not with family memories, warmth and affection but rather regulated by administrators with filing cabinets, staff shifts and often even staff uniforms.
Upon arrival, the baby will be placed in a cot like this:
And they will lie and wait and wait and wait. They will wait for the communication, affection and love that a newborn is pre-programmed to expect. But this is unlikely to ever come as large scale institutions have staffing structures that rarely allow for more than a couple of hours attention for each baby each day.
And this is just not enough to enable the healthy physical, emotional or cognitive development of the child.
And as days turn into weeks, and weeks into months, the baby learns to stop crying for attention and to stop expecting affection and love; the parts of the brain that regulate emotional relationships stop flourishing. Statistically, the child is unlikely to ever recover from this early neglect and may remain vulnerable for life.
Could it be different?
For many decades now there has been a consensus across pediatrics, psychology and neuroscience that one-to-one continuous contact between an adult (it doesn’t need to be a biological parent) and a child is needed for normal emotional, physical and cognitive development.
Can we rewind the clock and review the decisions that result in a baby, like the one in the photo, having such an unfair start in life?
What if during routine prenatal visits, a community nurse had the required skills and mandate to identify the risk of abandonment prior to birth, to counsel against it, and to link the mother to family support, social protection and other support?
And what if this could be reinforced by the doctor and the nurse in the maternity ward (over 97% of births in this region take place in a health facility)?
And if all of this failed, what if the baby was delivered to a warm and caring foster care family trained and motivated to give attention, love and affection to the child, while the social worker tries to find a long term home, either within the extended family or if not possible, within a suitable adoptive home?
In my recent TEDx, I talked about the lifelong impact of adverse childhood experiences (ACEs): sexual, physical and emotional violence, living in dysfunctional households plagued by poor mental health, addiction or domestic violence. The other major type of adverse childhood experience is neglect, and the plain truth is that the decision to place a child in a large scale institution results in neglect.
Even with the best of intentions, the human resource structure of large-scale institutions prohibit healthy childhood development, resulting in the neglect of children. It is therefore harder to imagine a decision that has more of an impact on the human rights of an individual than the decision a government makes about what to do with a child placed in the care of the state.
Prenatal interventions; better equipped maternity wards; family support services including cash benefits; even expanded emergency and regular foster care, either within or beyond the extended family; are much less expensive than large-scale institutions a) because the unit cost of childcare is less and b) because long-term health, social and other costs caused by poor outcomes for vulnerable adults from institutionalised backgrounds are high.
The wonderful 19th century French historical novelist Victor Hugo said, “nothing is more powerful than an idea whose time has come”. Thankfully, institutionalisation is an idea whose time has gone.
In December 2012, 20 UN member states across the region supported a Call to Action to eradicate placement of children under 3 in large scale institutions in collaboration with the Office of the UN High Commissioner for Human Rights, UNICEF & the European Parliament. This has to be a departure point for eventually eradicating the placement of any child in a large scale institution.
Under the leadership of the Montenegrin Prime Minister, a multi-sectoral drive for family-based care has seen a 56% reduction in the number of institutionalised children; strengthened kinship (within extended family) care; and a 7-fold increase in the number of children in non-kinship foster care in Montenegro.
A campaign to change negative public attitudes to children with disabilities – who comprise around half of those in state care in our region – has resulted in a dramatic increase in school inclusion and community-based services, thus reducing abandonment.
A long time ago, a model of state care was designed for children who had been abandoned. Strengthened prevention mechanisms are irreversibly reducing such cases. At the same time, public awareness of family violence is increasing and reporting is on the up.
Thus, the child protection system will gradually shift from providing care to abandoned children to protecting those at risk of harm within the family. At the heart of this shift has been the principle that children always need solutions where there is a consistent and solid presence of a trusted adult who will always put their interests first.
Anything less is tantamount to child neglect.
Benjamin Perks is the UNICEF Representative in Montenegro
Anyone who has been anywhere near a three-year-old recently will attest to their inexhaustible curiosity. They ask as many as 100 questions an hour – and around about the age of three, those questions switch from “what and where” to “how and why” questions – in a search for meaning in the world around them.
Early childhood is the optimum time for cognitive and sensory development and the years from three to five are when the executive function, also known as the human ‘air traffic control system’, is growing most actively.
Thus, the way parents, peers and the wider society responds to a three-year-old’s searching questions will be a major determinant of his or her education and life success, as well as their long-time contribution to economic, social and democratic development of their society.
This is why Nobel Prize winner, and one of the world’s leading economist, James Heckman calculated that the biggest return on investment from the public purse occurs in the earliest years of childhood.
Recent research has dramatically expanded our understanding of early childhood development and much of this new knowledge was sorely missing when the current education model of most countries was designed in the 19th century.
But today the disparity between those who don’t go to pre-school and those who do, seems clear. There is, for example, a correlation in mathematics outcomes for 15-year-olds who did not go to preschool being a year behind, among the 55 countries included in the OECD/UNESCO PISA study.
Thus in the last few decades there has been a huge drive in the world’s wealthiest countries to secure a pre-school place for every child. In the European Union, for example, the pre-school coverage rate is around 92% with a target of 95% coverage by 2020. Some countries such as Ireland and Latvia have had rapid growth in the past few years.
But what about low- and middle-income countries? In the draft United Nations Sustainable Development Goals, universal access to pre-school is set as a target for 2030. But there is a long way to go.
In the Central and Eastern European & Central Asia region – much of which borders the EU and is working towards integration with the EU economy – some countries have a coverage rate as low as 10%, much lower than the EU target of 95%. Here in Montenegro there is 52% enrolment of three- to six-year-olds in pre-school, but only 40% attend in real terms.
There is indeed a gulf between Montenegro and the European Union – which it eventually hopes to join. But there is also a geographical gulf and a poverty gap because a child born into the poorest section of society or the least developed municipality is nine times less likely to attend pre-school than one born in a wealthy family or municipality.
As in many countries, there are three drivers of poor attendance. The first is a lingering belief that pre-school is primarily for the purpose of daycare – not child development – and that this can be better provided at home by the extended family. There is a lack of understanding of the unique value of a professional and evidence-based pedagogical learning programme for the child.
The second is poverty and the inability to pay even relatively low fees for the service. This is coupled with the non-income dimensions of poverty such as the absence of a means of transport from often disparate rural locations to pre-schools in urban regional centres.
The third is the evolution of pre-school as a largely urban phenomenon for working families, which combine the functions of paedagogical development of children with daycare facilities such as kitchens, dining rooms and sleeping facilities where a child may stay all day, but where only 40% of the space and time is used for child development and where the investment and running costs can by disproportionately high.
The government of Montenegro has committed to increasing the enrolment of children in pre-school from 52% to 95% by 2020 with the technical support of UNICEF, through the establishment of a free-of-charge three-hour daily programme for all children, focusing on the poorest first. This will be achieved through innovative financing models and the establishment of pre-school facilities in primary schools, health posts, and other grassroots facilities in the disparate areas that are not covered by the current urban kindergartens. Shifts will also be developed in existing kindergartens to accommodate children during the afternoons for the three-hour programme.
Montenegro also joins Chile and South Africa as one of the three countries where UNICEF is working in partnership with the H&M Conscious Foundation to encourage an increased investment in ECD.
In addition, a public awareness campaign is underway to increase demand in areas where it is low. If such models can be replicated and mainstreamed through the aspiration for the sustainable development goals of the United Nations, we have a chance of reversing both the impact of inter-generational inequity between low- and high-coverage countries; the massive disparities between wealthy and poor children within countries like Montenegro; and the lost opportunities for all societies through a collective failure to respond to our latest knowledge on the essential need for early development of the brain when it is growing most rapidly.
Benjamin Perks is the UNICEF Representative in Montenegro
As you read this, a teen somewhere is making a decision they may regret for the rest of their lives, one with high costs for themselves, their families and their communities. Joining a gang or a terrorist organization or committing a serious crime.
Every teen everywhere faces a turbulent transition to adulthood: the rapid development of identity, blossoming of emotions and onset of puberty. Neuroscientists explain the turbulence as caused by asymmetrical adolescent brain development. The socio-emotional processing system starts to respond to incentives and provocations from the early teens, but the cognitive control system, which is needed to filter those decisions is not fully developed until the early twenties.[1]
Over the past twenty years, there has been good news and bad news in research on adolescence. The bad news is that many more children than we ever thought before are entering adolescence with broken childhoods characterized by heartbreaking adverse experiences: abuse, neglect and dysfunctional parenting driven by addiction, violence or unaddressed mental health issues. This is multiplied further in areas affected by conflict, crime, and poverty. Science shows that the more adversity experienced in childhood the more difficult it is for the adolescent to navigate his or her way around the opportunities and risks they face and to make sensible decisions that don’t harm them or their communities.
The good news from neuroscience is the discovery of neuro-plasticity — that teenagers can strengthen the performance of their “executive function”, the part of the brain that coordinates behavior, choice and reaction, through learning non-cognitive or character skills. Thus, as much as adolescence is fraught with risk and possible lifelong consequences, it can also provide a second chance to get teens back on track to lead a stable, fulfilling and happy life.
To divert for a moment from vulnerable children to all children, character skills are increasingly recognized in many countries as being as critical as IQ in determining academic and lifelong success for all. They are seen as essential for long-term economic competitiveness and socio-economic development and are being mainstreamed in K through 12 education. Character skills include instrumental skills such as optimism, curiosity, motivation, perseverance and self-control that drive overall performance in school and life. But they also include integrity and locally-determined values that ensure performance is harnessed to the common good and can contribute to shared expectations and values within communities.
In Harvard sociologist Robert D. Putnam’s recent best seller ‘Our Kids – the American Dream in Crisis’ on inter-generational poverty and the decline in social mobility, he reviewed all of the recent American studies on childhood and concluded that in addition to the impact of poor nutrition and material poverty on children’s life chances, parenting and schooling had a massive impact: “Well educated parents aim to raise autonomous, independent and self-directed children with high self-esteem and the ability to make good choices, whereas less educated parents focus on discipline, obedience and conformity to pre-established rules.” [2]
Whether talking about teenage ‘child soldiers’ in war-ravaged, poverty stricken countries, or abuse victims, or gang members in high-income countries, we need to look beyond obvious interventions that tackle material poverty or provide vocational learning or housing. If traumatic childhoods have left them with a chaotic and untrusting view of the world — they will find it very hard to hold down a job, or maintain a house, or build healthy relationships. We need to complement material interventions with the development of the type of character skills that will help them become more autonomous, self-directed and build more self-esteem to make good choices.
In Montenegro we have joined forces with Birmingham University to support the Ministry of Education in developing character education in schools and within a global partnership with ING to support the development of such skills with especially vulnerable youth in a non-school setting. This includes young people leaving state care, Roma and other minority children, and young people in conflict with the law.
Character education is only one part of a range of interventions that are needed to help young people get back on track. Vocational training, support for accessing basic health and other services and even psychological therapy are also essential. But character — skills including integrity — are an essential part of the jigsaw. While there is now a strong global investment case that public funds in early childhood promote positive life outcomes and long-term competitiveness, adolescence is our second — and perhaps last —chance to harness the public good to ensure our most vulnerable teenagers build better lives — and eventually better societies. Let’s not waste that chance.
Benjamin Perks is the UNICEF Representative in Montenegro.
[1] The Influence of Neuroscience on US Supreme Court Decisions about Adolescents Criminal Culpability. Nature Reviews Neuroscience. Laurence Steinberg. 2013 [2] P199. Our Kids-the American Dream in Crisis Robert D Putman Simon and Schuster
UNICEF/NYHQ/HartleyA young girl from girl from the Roma ethnic group stands in a field near the town of Podgorica in Montenegro.
“…….seeking but a moment’s rest among the long-forgotten haunts of childhood, and the resorts of yesterday; and dimly finding fear and horror everywhere….” [1] –Charles Dickens Martin Chuzzlewit London,1843
Everyone knows poverty drives inequity. Here in Montenegro one of the ways we address this is by supporting dramatic expansion of pre-school education for the poorest 3-6year olds, who are currently 10 times less likely to attend which ensures worse life prospects and an inter-generational cycle of poverty.
But is childhood adversity: violence, neglect and dysfunctional parenting, also a driver of inequity?
152 years passed between Dicken’s writing Martin Chuzzlewit and the discovery of a neurobiological explanation of how and why broken childhoods haunt and destroy adult lives-even into old age.
The Adverse Childhood Experience (ACE) study, launched in 1995, continues to demonstrate in many countries huge inequity between adults who were affected by high levels of child abuse, neglect or dysfunctional parenting, and those who were not. High childhood adversity leads to markedly worse outcomes in health, education, employment and crime. It is much more prevalent than we thought and occurs across wealth quintiles.
In addition to being one of the world’s finest novelists, Charles Dickens also gave an authentic voice to those whose childhoods had been pulled apart by the desolate loneliness and crushing injustice of childhood adversity and inequity as he had experienced first-hand himself [2]. As with Dickens, the passion of many UNICEF staff to tackle childhood inequity stems from our own childhood memories and in my case the experience of growing up in loveless institutional children’s homes has always been a major driver of my work.
At any given time across the region of CEE/CIS we have a million children in state care, a fact that will place them on a lifelong path of inequity.They come into state care because of childhood adversity or because they are abandoned, mainly into large-scale children’s homes. A placement in a children’s home is a secondary trauma for any child. It does not provide healthy attachment with an adult and this is particularly catastrophic for children under 5 when brain development is most active and dependent on consistent interaction with an adult.
Comparative brains scans as well as measurements of development-inhibiting cortisol levels between those in institutional care and those in strong families reveal a neurobiological inequity that will eventually translate into long term economic and social inequity.
A children’s home is a place where a child lives in a state of neglect – unequal not just in terms of poverty, but in terms of love, affection and attention. This is why 21 countries in our region have joined forces with the UN Human Rights Commission and UNICEF to eradicate placement of children under 3 in large scale institutions. In Montenegro there will be a complete end to placement of under 3s in state care by 2017. There is a similar campaign in Latin America where around 240,000 children live in state care.
The right to family life is being secured through stronger social work systems, which can keep families together, and promotion of fostering and other family based alternatives for children who cannot be cared for in the biological family. This has already yielded a 40% decrease in the number of children in institutional care in the past five years in Montenegro.
Children in state care are just the tip of the childhood adversity iceberg, the overwhelming majority of childhood adversity is suffered by children in families. We are thus working with health, education, justice and social work sectors to build systems which protect children and promote better parenting through pregnancy until adulthood. We work with government and women’s groups to break the taboo on childhood adversity-learning the lessons from similar efforts in the UK and Scandinavia a couple of decades ago. I recently did a TedX talk on this & was inundated with messages from Montenegrin adults who had been affected by childhood adversity and many had never told anybody. We launched the first study on child abuse in the parliament recently and next year we will launch and measure the impact of a public campaign on childhood violence and adversity. The aim is to reduce the space in which adversity is unreportable and invisible or even acceptable.
But how can we close the equity gap for adolescents whose lives have already been plagued by adversity?
Neuroscience may have taught us the bad news that when childhood adversity collides with adolescent brain development-it can put children on a lifelong negative trajectory : inequity, gangs, violence, but it has also taught us that the character and decision making skills required to prevent such a trajectory can be learnt thoughout childhood: grit, optimism, integrity and self-control for example . In collaboration with the Government, Birmingham University and ING, we are working with youngsters who have experienced high levels of adversity to teach these characteristics. We hope that this will help them to make better decisions , get back on track and close the equity gap between them and children from more stable backgrounds.
As international civil servants it is easier to talk about poverty than it is to talk about love. When we talk about adverse childhood experiences we are talking about love, a lack of love, or children being violated by those who should love them. We need to find ways of talking about childhood adversity as a major driver of inequity-despite the discomfort.
I would never want to lose sense of who I am and where I come from. Every month I join a group of young people who grew up in children’s homes in Montenegro and help them draw out their own potential to build better material and emotional future. I see my own reflection in their eyes and hope they will have a better tomorrow.
[1] Dickens, C. The Life and Adventures of Martin Chuzzlewit (1843), Chap. 25
[2] Tomalain C. Charles Dickens A Life 2011 Viking
Benjamin Perks is the UNICEF Representative in Montenegro
It’s hard to think of a crime whose victims are more faceless and vulnerable than victims of child sexual abuse. In most middle and low income countries, the subject of child sexual abuse remains largely taboo, without a social imperative to report suspicion of the crime within the community and with no ready help for children.
While efforts to address the subject of child sexual abuse can be sluggish, the ability of perpetrators to organize, network and harness technology is fast. The ever-expanding and accessible nature of internet and communication technologies has facilitated the distribution of child sexual abuse materials. The geographic boundaries between children and child sex offenders are reduced, resulting in new forms of online child sexual exploitation such as live streaming of child sexual abuse.
Online child sexual exploitation includes the production, distribution, possession and consumption of child sexual abuse materials (also known as child pornography). The majority of the victims depicted in these materials are very young children, often girls. The gaining of a child’s trust for the purpose of future sexual abuse through chatting online – also known as online grooming – constitutes another form of online sexual exploitation of children. The perpetrators employ numerous social engineering tactics and tools to lure vulnerable children and befriend the child, or harass them when they are non-compliant.
Globally, law enforcement agencies have suggested that there are over 17 million such images and videos in circulation – 83% of them include children under 12.
WePROTECT is a global initiative spearheaded by the UK Government to end online child sexual exploitation. At the heart of WePROTECT is a commitment by countries, IT industry, civil society organizations and UN agencies such as UNICEF to take coordinated national action to tackle online child sexual exploitation. This includes the development and implementation of technological solutions to identify, remove and reverse the spread of online child sexual abuse materials and to enable law enforcement agencies to bring the full weight of the law down upon the offenders, and in parallel, to provide of support services to child victims.
Montenegro is part of the WePROTECT initiative and has thus far supported the strengthening of intelligence led policing capacity to identify offenders and to build sound prosecution cases. We will also launch a nation-wide anti-grooming application available to all parents, children and schools in June 2016, which will enable children to review animated scenarios of what to do if a stranger approaches them on Facebook.
Simultaneously, we need to break the taboo on talking about sexual violence against children and undertake a national campaign on the topic soon.
Connectivity is essential for children in the 21st century and is key to their cognitive and emotional development and the fight against poverty. However, parents and teachers are not always aware of how to teach and monitor safe online usage. We must promote the We PROTECT programme globally – to balance protection of children from harm against promotion of digital citizenship and empowerment for all, including especially for the children themselves.
Benjamin Perks is the UNICEF Representative to Montenegro and recently did a TedX talk on the impact of adverse childhood experiences
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 1st, 2ndand 5thmost 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.
[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
[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
Benjamin Perks : Blogsite 
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