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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 inquiry in 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 how those 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.

Do mental health problems have their roots in the primary school years?

Recent reports have shown worrying rises in young people suffering from mental health problems. A study for the Department of Education showed more than a third of teenage girls reporting depression, anxiety and low self-esteem. To try to understand this growing problem, Dr Afshin Zilanawala and fellow researchers from the ESRC International Centre for Lifecourse Studies at UCL have investigated how certain aspects of learning in the primary school years and success affect the behaviour and wellbeing of early adolescents.

Young people who drink, smoke and have behavioural problems are known to be at risk of suffering poor health as adults.

Understanding what causes this risky behaviour, and the anxiety and low self-esteem associated with it, can help professionals to target those most likely to drop out of school, become pregnant as a teenager, become obese or to suffer other long-term health issues.

By planning support and prevention programmes during childhood, they can improve the likelihood of a successful and healthy adulthood for our most vulnerable young people, and reduce the pressure on health and social services.

Mental health

A recent YouGov survey of Britain’s university students revealed that more than a quarter of them report depression and poor mental health.

But could the roots of these problems be found by looking more closely at how children develop and learn throughout the primary school years?

Information on more than 11,000 children collected by the UK Millennium Cohort Study (MCS) was used in our research, which explores the links between children’s verbal abilities and their behaviour and well-being as they make the move to secondary school.

Using information collected at ages three, five, seven and 11, we were able to see how well they could read, the range of their vocabulary and their verbal reasoning skills.

Then, at age 11, the children were asked about their school work and life, their family and friends and their appearance. There were questions about how happy they were, whether they felt good about themselves. They were also asked if they had tried cigarettes or alcohol, and if they had stolen anything or damaged property.

Verbal performance

In terms of how well they were getting on, the children were divided into three groups (low, average and high verbal achievers).

This in itself produced a startling and worrying view of the diverging paths these different children follow over time, particularly between the ages of seven and 11. One in five of the children (the high achievers) did better and better at the verbal tests, stretching away from their peers as they prepared to head to secondary school. The majority (around three quarters) of children were on the middle path, making steady progress but then plateauing off. But, most striking of all was what happened to the low achieving group (around one in 17 of the children), whose verbal abilities declined steeply.

Verbal ability

Millennium Cohort Study

Having established these pathways, we went on to look at which children at age 11 were involved in risky behaviours and then to dig deeper to see how these behaviours related to their progress to date. We also looked at what other factors, especially those related to their family circumstances, might be at play.

Boys were more likely than girls to be smoking and drinking or getting involved in anti-social behaviour. Girls were more likely to suffer from low self-esteem. First-born children were happier and had higher self-esteem, and were less likely to smoke, drink and have problem behaviours than second or later birth-order children. Children with younger mums were also more likely to engage in risky behaviour.

Those from disadvantaged backgrounds and those with more unsupervised time were more likely to suffer from poor mental health. We also found those whose mothers suffered from depression were more at risk of mental health problems.

Looking at the raw data, the low achieving children were three times more likely to smoke than their high achieving peers and twice as likely as the average group. Low achieving and average achieving children were also more likely to drink.

One in three of the low achieving children compared with one in five of the high achievers had been involved in anti-social behaviour and were more than four times more likely to have behaviour problems as reported by their parent. They also had much lower levels of self esteem.

Family factors

When we took a range of family factors into account including the child’s age and gender, mother’s age and mental health and socioeconomic circumstances, many or all of the differences between the groups disappeared or became smaller, confirming the overriding importance of the family and social environment.

However, we can say, for the first time, and with considerable confidence, that how well children are reading, talking and reasoning, can and does influence their health and well-being as they become adolescents. Indeed, we found clear evidence that children who were performing below average in this area across childhood were more at risk of poor mental health and risky behaviour than their consistently above-average performing peers.

If we want those children to stand a better chance of a healthy and happy life, we need to focus a great deal of attention on what is happening at home and at school in those early years, particularly, our research would seem to show, between the ages of 7 and 11.

Our results are consistent with other research, which demonstrates the huge challenge for young people with poor verbal skills, who arrive at the doorstep of adolescence with mental health, self-esteem and behavioural issues, which are likely to continue into adult life.

Recent reports that child poverty figures in the UK are continuing to rise, despite successive Governments’ promises to reduce them, does not bode well in this context. Indeed, it would seem to indicate that it will be some time before the yawning gaps in inequality that we see at primary school and their knock-on effects on children’s wellbeing in adolescence can be closed.

Longitudinal Latent Cognitive Profiles and Psychosocial Well-being in Early Adolescence is research by Afshin Zilanawala, Amanda Sacker and Yvonne Kelly and is published in the Journal of Adolescent Health

Photo credit: Creative curriculum  US.Army

 

A risky problem: what can keep young people away from alcohol and cigarettes?

Smoking and drinking among very young people has been declining in recent years, but it’s not all good news. There is still a lot of public health concern around the numbers of older children who are consuming alcohol and cigarettes, as these are the young people most likely to come to harm as a result of drinking too much. Their risky behaviours are also likely to persist and intensify into adulthood. So what factors might prevent a young person from smoking and drinking in the first place? New research published in BMC Public Health shows that levels of happiness among children and awareness of the risks may be key to success. Lead author on the research, Noriko Cable, explains more. 

According to Public Health England (PHE), alcohol is now the leading risk factor for ill-health, early mortality and disability among those aged 15 to 49 in England. It wants to “prevent and reduce” the harms caused by alcohol. It also has ambitions to create “a tobacco-free generation” by 2025.

The most recent figures from the Survey of Smoking, Drinking and Drug Use Among Young People in England show that around 90,000 children aged between 11 and 15 are regular smokers and 240,000 have drunk alcohol in the past week. These figures are the lowest they have been since the survey began in 1982.

However, recent research published in BMC Public Health by colleagues at UCL, shows that around one in seven 11 year-olds is drinking alcohol and that having peers who consume alcohol makes them four times more likely to drink that their peers who don’t. We also know that smokers start young, two thirds of them before the age of 18.

So we wanted to examine more closely the sorts of things that might drive young people away from cigarettes and alcohol. In this way we hope to arm policy makers, health practitioners and those working directly with or caring for children and young people with information that can help with the development of clear policies and interventions.

Protective role

We focused on three factors thought to play a protective role in preventing young people from starting to smoke and drink. These were: their awareness of the harms, their well-being or happiness and how supportive their networks of friends and family were.

Information came from Understanding Society, a large UK survey, which, in addition to collecting a wide range of social and economic information from everyone in the household aged 16 and over, has a special self-completion questionnaire for 10-15 year olds. Our sample contained 1,729 boys and girls.

We examined answers at two time points (approximately a year apart) to questions about their smoking and drinking. With these two sets of information, we were able to see whether they had started but then stopped smoking or drinking, whether they were persistent users of cigarettes and alcohol, whether they had started between the first and second surveys (initiation) or whether they had not smoked or drunk alcohol at either point.

The children were also asked about how happy they were with different aspects of their lives, including how they were getting on at school, how they felt about their appearance, family and friends and life in general.

On a scale of 1-4, the children were asked to rate how risky they thought different levels of smoking and drinking were. They were also asked how many supportive friends they had; friends they could confide in.

Harm awareness and happiness

Nearly 70 per cent of the study participants described themselves as persistent non-users of alcohol and cigarettes, and around 13 per cent categorized themselves as persistent users. Persistent non-users scored highest on harm awareness and happiness tests compared to the other groups.

About 8 per cent of the study group labelled themselves as ex-users and about 13 per cent had started using alcohol or cigarettes between the first and second time they completed the survey. Young people aged 10 to 12 were more likely to be in the persistent non-use group, whereas participants aged 13 and above were more likely to be in the persistent user and initiation groups.

We were surprised that while, for most young people, knowledge of the potential and actual harms of alcohol and smoking was linked with them never drinking or smoking, for some it seemed to be associated with them starting to drink or smoke. It is possible that positive expectations from drinking alcohol or smoking cigarettes may, in some way, have overridden their awareness of what harm they could do.

The happier the young person was, and more aware of the harms of alcohol and cigarettes, the more likely they were never to drink or smoke. Having supportive friends to confide in did not play a role in preventing adolescents from using alcohol or cigarettes.

Promoting happiness and harms

So it seems that promoting young people’s happiness and well-being and making them aware of the harms of smoking and drinking may be key to keeping them away from alcohol and cigarettes. In terms of possible timings for information and interventions, another takeaway from the study might be that working with children between the ages of 10 and 12, before they start trying cigarettes and alcohol, could be important.

Because the information used in this study is self-reported, we need to interpret the findings with caution, but they do suggest that making adolescents aware of alcohol and smoking related harm can be helpful in preventing them from engaging in risky health behaviors.

Colleagues at the Centre are now getting to grips with the new age 14 data from the Millennium Cohort Study and, in collaboration with Mentor, a charity working on the ground in schools to tackle alcohol and drug abuse, are hoping to develop our growing body of evidence in this area that will help formulate policies and activities to make some of Public Health England’s ambitions around smoking and alcohol a reality.

Further information

What could keep young people away from alcohol and cigarettes? Findings from the UK Household Longitudinal Study is research by Noriko Cable, Maria Francisca Roman Mella and Yvonne Kelly and is published in BMC Public Health.