It would be impossible to forget Antonio. His abandonment and isolation had been so complete, nobody even knew how old he was. We guessed about 8 or 9. He lay in a cot, lifeless and listless in a dark corner. The lack of animation was the not the outcome of his severe disability and blindness but rather caused by extreme neglect. The institution “housed” around 150 adults and children. It reaked of human waste and human disregard.
My index finger gently brushed against his palm and he gripped it tightly as his face broke into semi-toothless smile. He had lived a life cut adrift from love, attention or even basic human acknowledgment .
Antonio’s story inspired a shared effort by the government of North Macedonia and the UN to end placement of children in large scale institutions. Children like him would be provided with family-based care, connection and stimulation in community settings.
The plan was knocked off script when locals in the town of Timjanik angrily refused a mayor’s request to accommodate some of the children . We went there with the minister to find out why. On arrival, we sustained a three hour volley of abuse and hostility from several hundred protesters. There was violence in the air. People watching this back in the capital on livestream were horrified. Pundits, influencers and activists began lambasting the protesters as primitive, callous and hillbilly.
We listened carefully. Their’s was a small town in decline. It could have been in Oklahoma or South Yorkshire.The townsfolk had previously been dependent on industry and agriculture. For generations their income and opportunities had been on a modest, upward trajectory. But they now feared their children would have a much more precarious future. They had lived with years of unfulfilled promises to fix their roads, improve their schools and provide a pre-school. They longed for someone to give a voice to them, alongside the regular campaigns they heard from human rights activists for migrants, sexual minorities and people with disability. Like Antonio, in their own way they felt abandoned.
But why did these two different forms of deprivation and abandonment compete with each other? Broadly speaking there are three catastrophic burdens in childhood that drive lifelong inequality:
Discrimination or Exclusion based on race, gender or disability for example. It creates barriers that exclude one from opportunities, justice and often the basic safety that others take for granted.
Income Poverty through a lack of the basic means to survive, thrive and access opportunities to reach one’s potential.
Emotional Poverty through the absence of the basic nurturing and protective parental relationships due to violence, neglect or other forms of dysfunctional parenting (also known as childhood adversity). This is often transmitted inter-generationally and unintentionally.
If you look at Black Lives Matter, Hillbilly Ellergy and Good Will Hunting through the lens of identity, they seem so different to each other. When we look at them through the lens of fairness and dignity for all, they seem the same. It sometimes feels like we have forgotten a sense of ourselves as a whole, we are looking for the differences and barriers. This fragmentation polarises us into differing sides in a counter-productive culture war.
People in places like Timjanik perceive human rights champions to be selective in the injustices they seek to address. Those living with rural and town poverty feel both politically and economically abandoned. They are at the fag end of a painful transition from an industrial to a knowledge economy. This transition has concentrated opportunity in large cities at the expense of almost everywhere else. Those same champions scratched their heads as populists have hoovered up support in poor and abandoned communities. Despite their best intentions, they must bear part of the responsibility for the growth in populism and polarisation.
I felt this recently back home when I took a group of young adult care leavers for lunch in London. They had each lived with all of the three catastrophic burdens described above. It is hard to think of a more deprived group in the UK. We walked past a protest march urging us to support the rights of an oppressed minority in a far flung country. The comparatively wealthy looking protesters obviously felt that from our position of privilege we should all support this vulnerable minority oversees and that this was the most important human rights issue of the moment. But whose privilege is it? One of the young people in our group said he could not imagine the same protesters marching for kids in care. To highlight injustice, without acknowledging it is not the only injustice is itself an injustice.
Coming back to the story of Timjanik. The following day at an unrelated press conference in the capital, we were asked by journalists about the events in the town. We were expected to join the public condemnation of the protesters behaviour. Instead we articulated the townsfolk’s grievances and their struggles and explained that we could understand them, though did not agree with them.
Within two hours our inboxes were flowing with warm messages from people in Timjanik. They had not expected that we would actually listen to them and tell their story. They had needed to be acknowledged and heard. To understand that we think they matter too. From a collective refusal to host the small group home just 24 hours prior, it was now back on.
From that moment on, we numerically balanced our public facing advocacy. We gave equal attention to the situation of the overall population and to those living with one or more of the three catastrophic burdens . If we did a public event on exclusion of Roma minority or children with disability one month, we made sure we also had an event on poverty or a population-wide issue like education or health the next. This struck us as fair, just and effective.
A few weeks after the protest, the government agreed a strategy to transfer all children out of large scale institutions through family re-unification, foster care and small group homes. The government named the strategy “Timjanik” in testimony to what we had all learnt from these events.
On October 15th last year, the last remaining children were removed from large scale institutions. The situation may have improved for children in state care in North Macedonia, but there is still so much to do to prevent exclusion, poverty and adversity in the lives of children the world over. We can only do this when everyone finds their place in a shared story of justice and fairness. We need to “re-universalize” our human rights story.
And the children in the story? Antonio is out of the cot, living in a small group home with adequate care and stimulation and for the first time in his life, he is enrolled in school. Today in Timjanik, the locals visit with cakes and play with the children at the small group home. Just ordinary people in an ordinary place with the extraordinary courage to reimagine a better tomorrow in a world that protects all of our dignity.
Amidst the fear and uncertainty of the Covid19 lockdown in China, 26 year old Lele experienced something more terrifying than the virus itself. Her husband fashioned a weapon from a kitchen stool and beat her semi-conscious as she held her 11 month old baby in her arms. There was nowhere to go, no services to support, no possibility to flee. She had to spend several more weeks with her abuser before she could reach safety.
On the other side of the world in Greenland, the capital city banned alcohol sales to prevent growing child abuse during lockdown. In India the were 92,000 calls to a child abuse helpline in the first 11 days of lockdown. France experienced a 34% increase in abuse helpline calls by children and an even bigger increase in the number of peers and school mates calling on behalf of friends. . As closed schools and stay at home orders spread, so did the risk of abuse.This pattern played out across the world, in three ways:
The first is the way that lockdown piles pressure on households . Even the calmest, securely attached and ‘child development-aware’ parents are being tested by ‘pandemic-parenting’. Often they are working in uncertain jobs while teaching ‘cabin fever kids’ while adapting to loss of space and privacy. But most will not suddenly become abusive or neglectful. In more volatile families however, this stress can spill over into violence or exacerbate existing abuse patterns. The biggest beneficiaries of #StayAtHome are the serial abusers who practice coercive control and other forms of psychological aggression. the lockdown increase the likelihood of adverse childhood experiences.
Secondly, the means of reporting severe child abuse or neglect have been dramatically reduced. According to the US Department of Health & Human Services child protection interventions are initiated by reports from teachers, social workers or nurses. Social distancing measures have reduced reporting. From the 1980s onwards increased reporting of family violence was a major mark of success and progress in protecting the rights of women and children. Momentarily, reporting is in decline.
The third issue, is complex but equally serious. In normal circumstances less than 1 or 2 % of children are subject to interventions by social workers. Yet Adverse Childhood Experience (ACE) research across populations suggests between 15 and 20% of children are affected by chronic, multiple forms of abuse, neglect or dysfunctional parenting at home. This 15 to 20% of children are now in a state of isolation. Children have a biological imperative to have protective, soothing relationships with an adult and are simply not built to be isolated. When a positive relationship at home is absent, the child interprets it at risk. It over-activates their stress response system which wreaks havoc on all aspects of healthy development. Unaddressed it can lead to catastrophic health and wellbeing outcomes throughout life. But when the stress is buffered and soothed by a healthy relationship with a teacher, grandparent or friend and the child is made to feel they matter on an individual level-then the recovery can begin. Right now around the world, hundreds of millions of children have been cut off from those relationships.
This is deeply distressing. Accounts of childhood maltreatment often recall a despairing loneliness and unbearable slowness. Loneliness when the parent who should soothe the pain, is actually the source of that pain. Slowness during long pauses of waiting for a violent outburst or scarce moments of maybe feeling loved. The isolation of the pandemic amplifies this pain exponentially. It is malleable with no end in sight. Relationships with teachers, grandparents and friends were cut off suddenly with no date for restoration.
We need to act with urgency on all three issues. Governments and communities could appoint ministers or local leaders to coordinate child wellbeing during lockdown. A priority must be engagement with parents on managing stress, home schooling and positive discipline, tailored to lockdown conditions. Online and media platforms could be adapted to facilitate a conversation with families and disseminate pandemic-specific parenting tips, similar to the global UNICEF parenting hub. Social protection and housing support must be adapted to reduce the stress on vulnerable families. Behavioural insights and technology innovations should be used to understand how we can best support parents and protect children.
Expanded helplines and channels that enable neighbours and friends to report maltreatment anonymously need to be provided . Equally we need to encourage extended family and friends to maintain regular communication with children in lockdown with abusive or neglectful parents. One of the most moving stories of the pandemic so far is the upsurge in calls by friends of victims reporting maltreatment in France.
Innovation and adaptation could help teachers and social workers restore normal levels of communication with children, despite lockdown. If they are not giving lessons, can they call each child for five minutes? These measures need to be population-wide and not just targeted to 1-2% of children who are child protection cases.
Decades ago, it became normal to ensure every child was immunised against deadly disease with a vaccine. In the future we could hope for a world were every child is buffeted from trauma by a calm and predictable adult connection. A world in which we improve prospects for parenting in every family at the earliest possible stage and maltreatment is managed and prevented as a part of routine public health . All we can do now is demand protection for Lele, her baby and millions of abused children and women locked down, unreported and isolated around the world as part of our immediate and shared struggle to defeat Covid19
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
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