What should we do about trauma?

He is 15-years-old and in a locked secure care home. Like all of the young people in his unit, 'Paul' has experienced a lot of adverse and traumatic events. By the time he was five he had been exposed to parental drug use and mental illness, domestic violence, physical abuse and neglect. At the age of 11 he was sexually abused by a step-grandparent. He has been violently assaulted throughout his childhood by strangers, peers and those who were supposed to care for him.

Paul is in secure care because he severely harms himself and other people in a context of drug use, homelessness and distress. Most will almost intuitively understand that Paul's difficulties are related to his early experiences. Yet it is only in recent years that we have seen a huge surge in interest in the role of adverse and traumatic experiences in later difficulties.

At the foundation of this is Felitti's Adverse Childhood Experiences (ACEs) studies from the late 1990s. One of his earliest studies, published in the American Journal of Preventive Medicine in 1998, asked more than 13,000 adult members of a health insurance scheme to rate their ACEs over various categories: psychological, physical or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. They then looked for relationships with adult risk behaviour, health problems and disease. Just over 70 per cent of those sent the questionnaire responded and the data gave three powerful messages; it showed that many had experienced ACEs (49 per cent had at least one ACE and 13 per cent had four or more ACEs); ACEs were associated with many problems in adulthood and this association was cumulative (the more ACEs, the more the risk increased); and those participants who had four or more ACEs were at particular risk (when compared to those with zero) of alcoholism, drug abuse, depression, suicide attempts, smoking, poor self-rated health and sexually transmitted disease.

Although it has taken nearly two decades, the movement that Felitti's work initiated has gained momentum in the UK in recent years. In 2013 Mark Bellis and colleagues completed the first UK ACE study in Blackburn with over 1500 participants. They too found that ACEs were strongly correlated to poor behavioural, health and social outcomes, including smoking, heavy drinking, obesity and imprisonment. In 2014 they published a larger study in BMC Medicine with 3885 English residents and found similar increased risks.

In 2016 Public Health Wales released an ACE study, again by Mark Bellis, that involved more than 2000 participants representing the general Welsh population. You can find the ACE categories and questions asked of participants in Table 1 of the report, downloaded via tinyurl.com/WalesACE. Beginning each question with 'While you were growing up, before the age of 18…', categories covered were sexual, physical and verbal abuse, domestic violence, parental separation, mental illness, alcohol and drug abuse, and incarceration. This study again found a relationship between adversity and later association with health-harming behaviours, mental wellbeing and chronic disease. It found that 14 per cent of participants had experienced four or more ACEs and that when compared to those with zero ACEs, these people were at much higher risk of a range of behaviours, including being 15 times more likely to have been violent in the last year, 16 times more likely to have taken crack cocaine or heroin and 20 times more likely to have been imprisoned.

The ACEs framework and its findings have profoundly changed research into child maltreatment by shifting the focus from the short-term effects of individual types of harm to the cumulative and long-term effects of adversity at adulthood. This has enabled very clear and powerful arguments to be made about the importance of preventing harm to children. It has also importantly validated the experiences of many adults who felt their early adversity had a role in their harmful behaviours.

A closer look

The ACE studies have got the attention of governments across the UK. The Welsh Government has invested in an ACEs hub that aims to 'tackle' their impact. Similarly, Scotland's First Minister announced last September that the Scottish Government would 'embed a focus on preventing ACEs and tackling their impact'.

It is easy to see why. The way the increased risks are reported is both accessible and powerful: stating that a harmful health behaviour is 14 times higher is likely to get most people's attention, whether trained in statistics or not. In contrast Mark Bellis's initial English ACE study reported the increased risks as the less accessible odds ratios – perhaps it received less attention as a result.

The ACE study results aren't only powerful due to their magnitude. They seem to speak to our experiences. Those who have worked with service users who had multiple and severe difficulties are often quick to recognise that they have had awful early experiences. There will be some exceptions, but not many. Different studies that have looked at prison, homeless and psychotic populations all highlight significant trauma and adversity in childhood. The ACE findings confirm what many of us see anecdotally in daily practice or even in our lives outside of work.  

The allure and power of these findings may explain why there has been surprisingly little critique of the research. But even a superficial review highlights three main problems.

First, although complex statistics have been used to measure relationships between adversity and later difficulties, they remain simple associations. With huge face validity it feels counterintuitive to question such relationships, but as every undergraduate learns we cannot assume causality until there are longitudinal studies or experimental designs to confirm it.

Fortunately, some very recent research has used a prospective longitudinal study to test the ACEs effect. Last year Joanne Newbury and her team, mostly psychologists based at the MRC Social, Genetic & Developmental Psychiatry Centre at the Institute of Psychiatry, Psychology & Neuroscience, found a powerful association similar to that which Felitti had found with remembered ACEs, which added greater credibility to his findings. But what was particularly special about this research was that as well as having participants remember their ACEs at age 18 the longitudinal design allowed the researchers to assess ACEs during childhood, at 5, 7, 10 and 12. There was only a 'slight to fair' agreement between ACEs recorded during childhood and those remembered at adulthood. Interestingly, the ACEs were higher during childhood than when the same participants were asked to remember them when aged 18. In contrast, those participants who had fewer ACEs recorded during childhood then reported a higher number when asked at 18. The authors concluded that the prospective method identified one group and the retrospective method captured another group, both having been maltreated. Importantly, both groups were more likely to have a range of psychiatric problems in early adulthood, and these associations were apparent regardless of how maltreatment was measured i.e. prospectively or retrospectively. The research needs to be replicated before solid conclusions can be drawn, but it at least suggests that an accurate measure of ACEs will only be gained if sought both during childhood and when remembered in adulthood.

The second problem is that ACEs are a clumsy way to measure adversity: they do not account for severity (how bad the adversity was), duration (a one-off event or chronic throughout childhood) or adversity beyond the 10 core categories (e.g. bereavement is not included). To illustrate, a child who was exposed to a single event where parents slap each other when drunk and arguing in an otherwise safe home, could have at least a similar ACE score to a child who was repeatedly exposed to parental alcoholism and severe domestic violence. Both are concerning and potentially formative to a child, but they are of a different magnitude.

The ACEs approach could therefore be seen as an oversimplification of a complex and nuanced mechanism of how powerful events contribute to child development. Adversity and trauma are often used interchangeably – this brushes over the plethora of theories about how to define and operationalise traumatic stress. The simplicity of the ACEs research – while doing much to convince people of the pathway to later difficulties – may also mean that readers and practitioners do not go further and look at separate research that is more nuanced and specific. There is a vast amount of literature that identifies relationships between specific traumatic experiences (e.g. sexual abuse) and particular difficulties. This includes the role of early traumatic experiences in adult psychiatric disorders, somatic disorders, obesity, addiction and criminal behaviour.  

Finally, the ACEs framework does not fully consider resilience and what determines how a child may cope or recover from adversity. Nietzsche famously wrote 'That which does not kill us, makes us stronger', and the ACEs framework leaves unanswered questions about both resilience and the conditions in which actual growth and learning can occur. If we were to ask Paul, from the beginning of this article, about his experiences, there would be more to them than simply bad events equalling bad outcomes. There would be subtleties, positive experiences and people who were kind and protective. The ACEs help us understand part of an individual's pathway to difficulties, but not all of it.

It's easy to discount these weaknesses of the ACEs framework, lest they detract from findings that so powerfully confirm our experiences and beliefs. But critique is important. The ACEs research is directly and meaningfully informing practice, and it is important to keep rooted in the evidence and balanced if we are to avoid overstating or misinterpreting the findings.

The translation of the ACEs ideas into practice is also beginning to cost money. This will mean it comes under increased scrutiny by the few who disagree with its central messages or their implications. Unless the ACEs findings are presented transparently and with the weaknesses acknowledged, there is the potential for a backlash that could risk losing the positive strides the ACEs framework has made.

The implications of a balanced view

The overall message of the ACEs research remains powerful. Cumulative adversity in childhood should be prevented and, where this has not happened, the effects of adversity should be responded to. Principles of child protection are rightly embedded in legislation, services and professional standards. The 1989 United Nations Convention on the Rights of the Child has 54 articles and the majority of these relate to protection from harm, with many overlapping specifically with the ACEs categories.There has been less focus on how to respond to the effects of adversity. Individual therapy approaches have much to offer here, and there is a substantial evidence base on trauma-focused therapies. However, this is a small part of how services can respond, and it has been argued that more can be gained if psychologists go beyond individual therapy and look at improving how services are delivered.

Trauma-informed care (TIC) has become the leading approach for those seeking to organise services that respond to the effects of adversity and trauma. Its principles have been implemented to child care, schools, and services for domestic violence, youth justice, homelessness and substance abuse.

As with any developing psychological concept there has been debate about how it is defined. At the core of all definitions is the idea that traumatic and adverse experiences of service users are acknowledged, understood and responded to effectively. Many have proposed core fundamental principles within this. Some of the most well known are those advocated by eminent trauma-informed care researchers Maxine Harris and Roger Fallot of safety, trustworthiness, choice, collaboration and empowerment.

Rochelle Hanson and Jason Lang tried to refine the concept and gain consensus on the core components of TIC in practice by seeking the views of hundreds of practitioners who worked with maltreated youths and their families. From this they suggested numerous components, under three levels:

• Workforce development: Require staff training in the impact of trauma; measure staff knowledge of this; prevent and help staff with secondary trauma; ensure they know when and how to access trauma-focused therapy.

• Trauma focused services: Use standardised and evidence-based assessments of trauma history and symptoms; include these in any file and care plan; ensure availability of trained, skilled clinical providers of evidence-based trauma-focused therapies.

• Organisational: Collaboration and information sharing within the agency and with other agencies, such as CAMHS and social work; procedures to reduce risk for re-traumatisation of children; input from children in service planning and development; services that are strength-based and promote positive development; a safe physical environment; explicit written policies; and a defined leadership position related to TIC.

There is also a wealth of resources out there for practitioners interested in developing trauma informed services, including a self-assessment tool by Fallot and Harris (see tinyurl.com/ndpzeuj).

Such work is fuelling interest in TIC that is paralleling the ACEs movement. More and more services are saying they are 'trauma informed' and there are specific trauma-services within the NHS and private sector. TIC is not without problems though. A common criticism is that it lacks distinction from the principles of what any good care should be for anyone, regardless of whether they have experienced adversity. For example, which of us would not expect safety, collaboration and the like from any health service? While Hanson and Lang tried to isolate those components that distinguished TIC from good care, there remains overlap.

The implications of this are perhaps not too concerning. For those services that are already driven by a clear model of good care, the principles of TIC may augment them or provide a useful contrast. For those services that do not have any explicit principles guiding them, TIC can fill this gap. Concerns about providing TIC to those who have not been exposed to adversity can be alleviated by considering that those most likely to need services are those who have experienced most adversity.

What are psychologists to do?

Kathryn Becker-Blease notes the interest so far has been a good thing, but work is still needed in order to ensure TIC reaches its potential to be meaningful and effective for service users. If not, it risks becoming just another acronym, a passing fad. So let's focus on four key areas:

• Implementation: Collaborate with other practitioners to help translate TIC theory into tangible, practical and useful practice. Psychologists' skills in supporting fidelity to the core principles and integrity of delivery will help prevent services tokenly purporting TIC when in fact practice has not changed.

• Evaluation: Develop an evidence base on application in a range of settings. There is relatively little evidence about whether it works in the real world, what factors are associated with success or failure and how it works with different groups or services.

• Training: Ensure quality and evidence-based training that ensures skill development and competency. The NHS Scotland Knowledge and Skills Framework provides an excellent resource on which to base training and competency development.

• Advocacy: Service users should be empowered to choose and determine the services they receive. To resist or under-deliver on this principle risks creating services that disempower and replicate power imbalances that are at the core of many children's adverse experiences.

The ACEs research has provided a powerful message: cumulative adversity contributes to long-term health and behavioural difficulties for many. The science has weaknesses, but exploring and acknowledging these will balance responses and avoid a harmful backlash.
It is a crucial time in deciding how we respond to adversity. Trauma-informed care has real potential to improve services for those who need them most. Psychologists can help by ensuring high-quality evaluation, implementation, evidence-based training and fidelity to core principles. With their contribution TIC may make meaningful improvements to the lives of individuals who need it most.

About the author

'I've worked in secure settings for almost 20 years and it is hard to ignore the high levels of adversity that people there have experienced. I'm passionate about raising the ACE framework as it fits so closely with my daily experience and points us to some useful actions, including child protection. What's missing, though, is a clear plan about how to respond. This is hopefully where trauma-informed care has promise. Only implementing it in an authentic and tangible way will let us know if its a useful approach or not.'

- Dan Johnson is Forensic Psychologist and Clinical Director with Kibble Education and Care Centre in Paisley
[email protected]

References

Becker-Blease, K.A. (2017). As the world becomes trauma–informed, work to do. Journal of Trauma & Dissociation, 18(2), 131–138.

Bellis, M.A., Lowey, H., Leckenby, N. et al. (2013). Adverse childhood experiences. Journal of Public Health, 36(1), 81-91.

Bellis, M.A., Hughes, K., Leckenby, N. et al. (2014). National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine, 12, 72. doi:10.1186/1741-7015-12-72

Bellis, M.A., Ashton, K., Hughes, K. et al. (2016). Adverse childhood experiences and their impact on health-harming behaviours in the Welsh adult population. Cardiff: Public Health Wales.

Carr, C.P., Martins, C.M.S., Stingel, A.M. et al. (2013). The role of early life stress in adult psychiatric disorders. Journal of Nervous and Mental Disease, 201(12), 1007–1020.

Danese, A. & Tan, M. (2014). Childhood maltreatment and obesity: Systematic review and meta-analysis. Molecular Psychiatry, 19(5), 544–554.

Felitti, V.J., Anda, R.F., Nordenberg, D. et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258.

Hanson, R.F. & Lang, J. (2016). A critical look at trauma-informed care among agencies and systems serving maltreated youth and their families. Child Maltreatment, 21(2), 95–100.

Harris, M. & Fallot, R.D. (Eds.) (2001). Using trauma theory to design service systems. New Directions for Mental Health Services No. 89. San Francisco: Jossey-Bass.

McGrath, S.A., Nilsen, A.A. & Kerley, K.R. (2011). Sexual victimization in childhood and the propensity for juvenile delinquency and adult criminal behavior: A systematic review. Aggression and Violent Behavior, 16(6), 485–492.