Time to ACE the way we measure the bad things that happen to children

Adverse Childhood Experiences (ACEs) have been a hot topic for policy work in child health and development in recent months. The Select Committee for Science and Technology announced an inquiry into evidence-based early-years interventions, with a particular focus on ACEs. Also a new All Party Parliamentary Group for the Prevention of Childhood Adversities was set up. Essential to the success of these policy initiatives is a fit for purpose method of measuring the negative things that happen to people when they are young, something Rebecca Lacey from the ESRC International Centre for Lifecourse Studies at University College London argues is often overlooked. As part of a new research project, she is hoping to change that.

When Norman Lamb MP launched the early-years intervention inquiryin late 2017, he expressed concern that research in this area was “not being effectively used” in the creation of health policy and other support arrangements. Part of the problem with effective evidence in this area is that the system used to ‘score’ the number of bad things that have happened to a child and assess their risk of poor outcomes later in life is often poorly thought through and rarely questioned.

In 1998 a landmark piece of research by Vincent Felitti and colleagues showed that adults who reported being abused as children, witnessing violence against their mother, living with a substance misuser, or someone who had been in prison or had a mental illness had an increased risk of numerous health problems, such as depression and drug misuse, when they grew up.

It also showed that the number of adversities that someone reported having experienced as a child was really important; the more adversities reported, the higher the risk of health problems in adulthood. This number of adversities is often known as an ‘ACE score’ and Felitti’s paper was the first to use this approach for childhood adversities. It’s an approach that has since been employed in hundreds of academic studies.

Advantages and disadvantages

ACE scores have several advantages. They’re easy to calculate by simply adding up the number of adversities each person has experienced. In a clinical setting, a simple screening tool can be used to identify people at particularly high risk of health problems. These are generally people who have experienced four or more adversities, regardless of which ones.

This approach also acknowledges that people reporting one adversity are much more likely to have experienced at least one other. In Felitti’s study more than half of the people reporting that they’d been psychologically abused as a child had also been physically abused. Similarly, 3 out of every 5 people who had a family member in prison also reported that someone in the household had substance misuse problems. This clustering of adversities is crucially important to recognise both in research and in policymaking.

However, there are many reasons why ACE scores aren’t helpful for policy use. In fact they were never ‘designed’ with policy use in mind. Because they lump together adversities which are often very different (for example, experiencing abuse is likely to be a different experience to having a parent in prison), it’s difficult to tell which adversities have the potential to have the most harmful effects on health. We also don’t always know a lot about howthose adversities affect health. Knowing this information would help us to better inform where to target policies. The problem is further confused by different studies including different adversities in their ACE score. So when looking at the findings of different studies you can be comparing apples and pears.

Policy relevance

The heightened interest in ACEs combined with the recognition that early life is important for how a person’s life will pan out is really good news. But we do need to think more carefully about how we measure adversities in research and in particular how we can make our research more policy relevant.

For instance, if there’s a limited budget, which adversities would you try to tackle first? Are there particular childhood adversities which increase the risk of a child experiencing many other adversities? How do different types of adversities affect health? Is it appropriate to lump together very different types of adversities into an ACE score or is there a more appropriate way of treating the clustering of adversities in a less crude way? These are just some of the questions that need to be addressed quickly.

 Whilst the research is underway, there are a few things that researchers and policymakers can think about. As a starting point researchers and policy makers and practitioners interested in this area need to think more critically about how adversities are measured, with an aim of being more meaningful and policy relevant. What do we and don’t we know by using ACE scores? What other approaches to adversity measurement could we explore?

Longitudinal studies are key

Longitudinal studies, such as the British Birth Cohorts, which collect information on children and their family circumstances over their lives, are key to improving the evidence base on ACEs and health. Many of the existing studies on ACEs and health have relied on people recalling information on what they experienced as a child. This is prone to error and bias, and can be affected by what people are experiencing at the time they are asked, such as depression or stress at work.

These studies can also help us better understand whether and how timing matters. Not only can we ask which adversities appear to be particularly harmful for health, but also, when exposure to specific adversities are particularly harmful. By doing this/taking this kind of approach, we can also identify the most fruitful times to intervene to help people flourish across their lives.

Finally, the communication of risk is really important. There are many advocates of ACEs who directly translate findings from observational, population-level research into their work with individuals. For instance, if a research study shows that children who experience 4 or more adversities are on average 6 times more likely to be depressed in adulthood, this doesn’t mean that every individual who experienced 4 adversities will be 6 times more likely to have depression in adulthood. This approach of directly translating population risk is not appropriate and if done means that research often gets miscommunicated in a way that’s too deterministic. The health (or other) consequences of ACEs are not inevitable.

The recent increase in policy interest gives us an opportunity to achieve a step-change in the way we look at adverse childhood experiences.  If we seize this opportunity, the research community can play a key role in supporting the desire of policy makers and politicians to be effective in achieving their aim of helping at-risk children, adults affected by earlier bad experiences, the NHS, all those working in this area and UK taxpayers.