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Published, 10 October 2016

An ‘ACE’ look at mental health

Today is world mental health day so we've got an article from the archive from Professor Michael Smith that looks at childhood experiences and their impact on mental health later in life. (Article extracted from REACH magazine - Autumn 2015)

If prevention is better than cure, is there anything we can do to reduce the prevalence of addictions and mental illness? The answer is a determined and optimistic yes.

Childhood influences many of the problems in adult health

Many of the problems affecting adult health were influenced decades earlier in childhood. Our insight into this phenomenon owes much to research that began in California 20 years ago. 

In the mid-1990s, a group of researchers defined Adverse Childhood Experiences (‘ACEs’) as ten kinds of harmful life events. They include

  • physical, sexual or emotional abuse;
  • physical and emotional neglect; and
  • forms of ‘household dysfunction’ including things like experiencing domestic violence, divorce, or a relative in prison.

This isn’t an exhaustive list. Severe bullying, for example, isn’t included, but we now know that it can be as harmful as other forms of childhood maltreatment. Nonetheless, counting the types of adversity experienced before 18 years gives an ‘ACE score’ that is closely connected to life chances and health outcomes.

Adversity affects most people

Adversity affects almost everyone at some time in their lives, and two thirds of the population has some form of ACE score. Most people seem to be able to cope with up to three ACEs in their childhood without long-term problems. For example in a recent British study:

  • People with ACE scores of 1-3 each had a 50% chance of living into their sixties without a major health problem.
  • But people with an ACE score of four or more had only a 20% chance of staying healthy.
  • If you’ve been exposed to four or more ACEs, it’s not so easy to achieve your potential, or to stick to the life path you might have chosen.

In fact, the more ACEs you’ve had, the more the odds start to get stacked against you.

Higher ACE scores are associated with being depressed or suicidal, with hallucinations, medically unexplained symptoms, impaired memories of childhood, poor work performance, and unstable relationships. ACE scores are especially high amongst prisoners and people who are homeless.

There’s nothing inevitable about this: some people with high ACE scores do well, often because of secure attachment relationship to adults which are able to compensate for the stress and distress of adversity.

Nonetheless ACEs are powerful, and their effects long-lasting. As Vincent Felitti, one of the original ACE study investigators put it:

“Traumatic events of the earliest years of infancy and childhood are not lost but, like a child’s footprints in wet cement, are often preserved lifelong. Time does not heal the wounds that occur in those earliest years; time conceals them. They are not lost; they are embodied.” 

Enabling better life chances for children in Scotland

Improved Child Protection measures, our efforts to Get It Right For Every Child, and initiatives like the Early Years Collaborative are crucial parts of enabling today’s children in Scotland to have better life chances than their parents and grandparents.

But thinking about ACEs can help us to refine and extend that work. For example, although the biggest impact of ‘early years’ interventions might take place from the prenatal period up to two years old, that’s not to say that older groups and particularly children and young people who are looked after, cannot benefit too.

The ACE studies also make it clear that lasting harm can be caused by experiences that are far below a threshold for statutory child protection interventions.

Health and social services are tackling underlying ACE problems

ACEs underly a lot of the problems that health, social care, addictions, education and criminal justice services must respond to.

We could do more to share our knowledge and skills, so that we can respond to vulnerable people across the range of services. Many of our systems and public institutions might look rather forbidding and inaccessible to someone with a history of trauma or neglect who is seeking help.

Care in services depends on relationships, and we should ‘ACE-proof’ our organisations as far as we can.

Poverty, inequality and ACE

Much of Scotland’s poor health relates to the effects of poverty and inequality. But that’s not the whole story: even after taking deprivation into account, Scots (and especially those Glasgow and the West of Scotland) are still more likely to die young. About two-thirds of that ‘excess’ mortality is due to suicide, drug misuse, alcohol misuse and ‘external causes’ (including violence) - each strongly influenced by childhood experiences. It is plausible- though untested- to think that ACE reduction might lead to lower mortality from these causes.

Looked after children and ACE

But of all groups in society, looked-after children and young people are probably most affected by high ACEs, and least likely to have experienced the protective influence of secure attachment. As ‘corporate parents’, we are rightly concerned about the high rates of suicide, self-harm and substance misuse in young people who have experienced care. ACE work also helps us to the higher rates of personality problems, educational underachievement and offending behaviour that affects looked-after young people. 

I remain optimistic, despite these difficulties. We are aiming for three things: fewer ACEs, more secure attachment, and communities who can work to bring that about. That’s not easy to achieve. But it’s a challenge we need to rise to.


Article from our REACH magazine - Autumn 2015 


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