Critically Revisiting the Foundational Studies on Adverse Childhood Experiences

This blog is based on an article in Social Policy and Society.  Click here to access the article.

Adverse Childhood Experiences (ACEs) research and policy have gained traction in the UK over the last decade. ACEs research, originating in USA in the 1990s has been reproduced in the UK, generating a movement in family and social policy circles. The first study, conducted by Felitti and his colleagues in 1998, found that children who experienced serious neglect, abuse and household dysfunction were at risk for poor adult health and social outcomes ranging from heart disease and diabetes, depression, suicide attempts and domestic violence. The original study has become a catalyst for numerous studies on ACEs over the last decade making claims about the intergenerational consequences of ACEs, their direct impact on the developing brain and promoting primary intervention at a family level.

ACEs have entered popular culture and everyday conversations with articles in The Guardian about how ‘childhood stress can knock 20 years off your life’, and terms such as ‘ACEs scores’, ‘toxic stress’ (coined by Jack Shonkoff of Harvard University’s Center on the Developing Child), ‘trauma- informed’ services and ‘bio-behavioural markers’ being thrown around in early intervention policy and practice. At the Center for Youth Wellness in the USA, public health advocates accept childhood adversity to be a ‘hidden health crisis’ with ‘far‐reaching consequences’.

There is a growing criticism of ACEs research and practice, particularly concerning the causal claims made about the link between childhood adversity and adult outcomes and the validity of retrospective self-reports about childhood experiences; definition of ACEs and the location of adversity within the home and parenting practices; cultural and generational differences in how childhood experiences and family relationships (eg, displays of parental affection) are construed and adversity is perceived; and the shaping of prevention policies in ways that do not address the social and economic conditions that produced adversity in the first place. Policy priorities have shifted towards tackling the intergenerational transmission of ACEs via family instead of population-level interventions.

ACEs are defined along the lines of childhood abuse and household dysfunction (i.e., physical, verbal, and sexual abuse, parental separation, exposure to domestic violence; and growing up in a household with mental illness, alcohol abuse, drug abuse, or incarceration) but not in terms of food insecurity, unaffordable, and often inadequate, housing, societal marginalisation, decrease in living standards or inequality. The social determinants of adult health and wellbeing and the biological embedding and durability of socioeconomic differences in health across the life course are systematically ignored. The ACEs framework is deficit driven in that it focuses on risk factors without taking into account protective factors and resources in communities (eg, social networks, extended family) that may function as a ‘buffer’ against adversity and support resilience in childhood.

Furthermore, ACEs studies claim a causal trajectory of ACEs and reduced social mobility in families, promoting a culture of blame for parents for exposing their children to intergenerational disadvantage; essentially blaming them for systemic inequality and reduced social mobility. The shifting of policy focus on what parents do at home to ameliorate the effects of disadvantage and become ‘less coercive and more nurturing’, as Bellis and his colleagues stated in their 2014 study, sets a worrying trend by proposing individual solutions such as parent behaviour changes to political problems of structural inequality.

On both sides of the Atlantic there is a growing recognition of the effects of poverty and disadvantage on health and educational outcomes for children, and that to reduce health disparities by socio-economic status we need systemic changes, arguing for community level interventions to equalise opportunity and increase life chances. In their 2017 report, the Royal College of Paediatrics and Child Health found that poverty impacts upon children’s developmental, cognitive, educational and long-term social, health and behavioural outcomes in adulthood.  Societal conditions such as increasing financial inequality marked by a steep decline in the proportion of families on middle class income contribute to ACEs. These findings are particularly relevant considering that, currently, 1 in 5 children in the UK live in conditions of poverty and this figure is projected to rise as austerity is here to stay.

As currently conceptualised, ACEs do not help with disentangling the roots of toxic stress in families. We need to expand adversity beyond household and the family. To this end, we need a better understanding of the sources of stress in children’s immediate environment that emanate from lack of material resources and opportunities in the era of ‘gig’ economy rather than lack of parental nurturance. And this understanding needs to inform prevention policies. Boosting resilience in children and their families requires a collective effort through developing social networks (e.g., friends, extended family members, civic/faith groups) and public services fit for purpose such as childcare (e.g., Sure Start) and comprehensive parental leave to balance work and family commitments.

As discussed in my article on ACEs foundational studies, there is little doubt that poor adult health emanates from health inequality and inequality of opportunity. If the aim of public policy is to prevent health inequality at a population level, the effects of poverty on children’s development and family wellbeing should be accounted for. To their credit, the authors of the original ACEs study talked about social change as a mechanism to prevent ACEs by understanding the role of social determinants in health outcomes and health discrepancies triggered by social class. ACEs are found across the social class divide; however, resilience and copying capabilities differ across social groups depending on the existence of collective systems of support. By confining ACEs within the household we inadvertently promote policies that constitute parents responsible for childhood adversity.

About the author

Dimitra Hartas is Associate Professor at the University of Warwick


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