Facing Our Past, Finding a Better Future – Adverse Childhood Experiences

This week I had the privilege of listening to Prof Warren Larkin, advisor to the Department of Health on Adverse Childhood Experiences. This is something I’ve written about on this blog before and Warren has made me more determined than ever to keep talking about this profoundly important issue. This blog draws on his wisdom and learning.

I believe that Adverse Childhood Experiences are our most important Public Health issue. So I want to be really clear about what they are, how and why they affect us so deeply, where we can find help if we’ve been affected by them and how together we can change the future, by preventing them.

 

What Are Adverse Childhood Experiences?

 

• Physical abuse
• Sexual Abuse
• Emotional Abuse
• Living with someone who abused drugs
• Living with someone who abused alcohol
• Exposure to domestic violence
• Living with someone who was incarcerated
• Living with someone with serious mental illness
• Parental loss through divorce, death or abandonment

 

How Common Are They?

 

The answer is – far too common. There have been some really wide ranging studies across the UK and USA into the numbers of us who have experienced ACEs, and it’s not just in our “most deprived communities” but in predominantly white, middle class areas where we see the stark statistics. Depending on the study you read, between 50 and 65% have experienced at least one ACE. And shockingly 1 in 10 of us have experienced more than 4.

 

How and Why Do They Effect Us?

 

Firstly, they affect us by quantity. The more ACEs we experience, the worse our physical, mental and social health and wellbeing is. If you have experienced one ACE, you have an 86% chance of being subject to several. If you experience more than 4, your health and wellbeing is significantly affected. If you experience more than 6 then you have a 46 times higher chance of becoming an IV drug abuser, a 35 times higher chance of committing suicide and an overall 20 year decrease in life expectancy.

 

Secondly, the toxic stress levels significantly change the way in which our brains grow and function. This has a profound impact on our day to day functioning. ACEs are a massive cause of absenteeism from work, high cost to the health and social care system and highly predictive of time behind bars. That is why so many of us have complex relationships with things like food. Losing weight, for example, is not as straight forward as eating less, exercising more or ending up with a gastric band. Did you know that suicide rates are massively increased after bariatric surgery? By removing the ability to eat, the very thing that takes away or comforts the pain, we expose the underlying issue, but provide no healing into that void.

 

Thirdly, our bodies literally keep the score of the negative experiences. So, we become more likely to develop chronic pain, inflammatory conditions, heart disease, cancer and mental health issues.

 

Fourthly, the toxic stress actually alters the way our DNA works and therefore changes the genetic information that we pass onto future generations. As an example, domestic violence in pregnancy is predictive of child developmental issues and offspring of the survivors of the holocaust or genocide are far more likely to develop chronic anxiety. This highlights just how important our family history really is.

 

Fifthly, there are proven things we can do a) to help our brains learn how to cope in the midst of really difficult circumstances (resilience) and b) therapeutic interventions that can genuinely heal us.

 

Where Can We Find Help?

 

Here’s the thing – this is where the rubber hits the road.

 

Many of us, who have experienced difficult things in childhood/adolescence never talk about them. Sometimes that’s because we can’t remember the experiences – they happen to us before our memories fully form. But perhaps more frequently we bury them because we don’t want to talk about the deeply painful memories, we don’t know how to or we’re worried about what might happen to us, or the people who caused us the pain if we do. And how do you start a conversation like that anyway? What? Are you going to just blurt it out to someone? And what on earth will you do if you just start crying in the middle of a restaurant when you talk to your girlfriend/boyfriend about what happened to you? And what about all those complicated associated feelings of shame, guilt, fear, thoughts of rejection? So…..we keep the lid on….even though it’s to our own detriment because we don’t know how to bring it into the open.

 

And here in lies the starting place. It’s vital that we learn this in the world of health and social care, but actually we all need to hear this incredible truth. Various studies have shown that it takes 9-16 years for people to be able to talk about trauma/abuse they experienced, but most never do. Fraser and Read found that in their patients struggling with mental health issues, only 8% of them volunteered that they had experienced ACEs. However, when they were actually asked about this, 82% then talked about ACEs they had experienced. So? So, we find it almost impossible to talk about, but when someone asks us about what we have lived through, it takes the lid off the box, peels the sticky plaster off the deep wound and allows us to begin talking about our pain. And here’s something really remarkable……Felitti and Andra found in a study of 140000 people that simply by routinely asking all patients about ACEs, they saw a 35% decrease in visits to the GP and an 11% reduction in use of the Emergency Department!

 

What does that mean? It means that giving someone the chance to talk about their journey, what they have been through, breaking the cycle of shame, fear and rejection is, in and of itself, deeply healing! Knowing that you’re not a freak, knowing that it wasn’t your fault, knowing that it doesn’t mean that you yourself will become an abuser/alcoholic/poor parent and many more realisations can make a significant difference to a person’s wellbeing. Maybe it doesn’t have to wait for a GP’s surgery or a counsellor’s chair. Maybe, just maybe if we all care enough to ask each other deeper and more caring questions we can help to heal each other. I know this is true of my own journey and that of many of my friends.

 

But let’s not be naive. For some of us, the experiences we have had are so horrific that we are stuck in a moment and we can’t get out of it. And this is where good therapy really comes in. I wonder if we invested more in therapy and less in drugs to numb our pain, how much more healed we might be – perhaps more expensive in the short term, but overall the cost is far less, both for the individual and society as a whole. There is help available and it can take many forms. EMDR, Trauma Focussed-CBT, Bereavement Counselling and even things like working through a forgiveness process. Unfortunately, many of the waiting lists are very long, and private options are way too expensive for most people to afford.

 

So, Can We Change The Future?

 

You know that I believe together we can! But it’s not going to be easy, especially not in the context of our floundering social services, restrictive school curriculums, reduction in numbers of health visitors and school nurses, eye watering cuts to public health budgets and significantly stretched CAMHS and Adult Mental Health Teams. And I think we have to very real and honest about that, because if this is such a massive issue in our society (and the data and evidence is astounding) then we need, as Warren Larkin so eloquently argues, genuine commitment from leaders and organisations to shift towards a culture of learning and collaboration to bring about change.

 

Here are some things we need to do together:

 

1) Own up to what a massive issue this is.

2) We need to learn how to ask our friends better questions and care enough to listen to each other’s experiences and journeys because it is really hard to know how to start talking about ACEs, but is more possible when someone bothers to ask!

3) We need to recognise that by bottling things up, we do further harm to ourselves. Perhaps some of our complex addictive patterns of behaviour, our mental health issues, our physical pain and symptoms might well be linked to the ACEs we have experienced. So maybe we don’t need a life on painkillers, cigarettes or with a complex addictive behaviour patterns. Maybe we can find a way to deeper healing.

4) In health and social care, we need to adopt REACh (routine enquiry about adversity in childhood) – we need to change the way we take histories from patients and ask better questions. Remember that even by asking, it doesn’t open up scary and messy consultations that we don’t have time for, actually it opens up a therapeutic space which can massively alter how a person goes on to use the health service in the future.

5) We need to ensure schools are more vigilant to thinking that ‘naughty’ or ‘difficult’ children are actually highly likely to be in a state of hyper vigilance due to stressful things they are experiencing at home. Expecting them to ‘focus, behave and get on with it’, is not only unrealistic, it’s actually unkind. Simply recognising that kids might be having a really hard time, giving them space to talk about it with someone skilled, teaching them some resilience and finding a way to work with their parents/carers via the school nurse/social worker could make a lifetime of difference. It is far more important that our kids leave school knowing they are loved, with a real sense of self-esteem and belonging than with good SATS scores or GCSEs. The academic stuff can come later if necessary and we need to get far better at accepting this.

6) Parenting classes should not just be for the well-motivated or struggling. They should be for all of us – a routine part of antenatal care and alongside our children’s education and include help in dealing with previous ACEs, so they are not repeated for the next generation. Prevention is possible. And that means we need to learn to be a whole lot less judgemental and a great deal more open, honest, vulnerable and restorative with each other. One of my best memories of growing up, was going to a “foster home” for families that my mum used to work with and seeing parents being given the chance to learn how to love their kids, rather than have them taken off them. I know sometimes there is no choice, but helping people learn how to be family and to love and cherish their children is a really beautiful thing. When there has been generational abuse, it is is also of the upmost importance. I’m not saying that a child should never be removed, but we can hardly say that our care system is a rip-roaring success story.

7) We need to find a way of working with men and women in our prisons that enables them to find a way to healing and restoration, not retribution for what are often extremely complex stories.

8) We must learn from best practice around the world. For example, did you know that the vast majority of paediphiles begin offending at the age of 14?! Most of them do not go on to become prolific offenders, but the damage caused to the child they abuse is obviously significant. There is some amazing work now going on in Pennsylvania which has shown that you can actually prevent young men from becoming offenders in the first place. Simply by doing some better sex education, explaining to boys about testosterone, the urges they are having and who it is appropriate to perform sexual acts with; alongside creating a really safe space where they can come and talk about feelings they are having (a bit like AA – with no ridicule or judgement) – data shows that you can decrease the incidence of child sexual abuse. We have to learn from this kind of approach and find a better way of talking about difficult issues. Prevention IS possible!

9) We need to find a way to fund more psychological therapies and become much less reliant on drugs to numb the pain with the associated colossal bill paid to Big Pharma.

 

 

This is an area I am really passionate about. I am committing to keep this conversation alive, to ensure that we make a shift in our organisations towards a REACh approach, to find a deeper and more effective partnership with colleagues in education, social services and the police and to create space for more training and awareness for all our staff teams. I know how painful this conversation is, but I also know how utterly damaging it will be if we don’t change the future and prevent this from being a perpetual story through the generations. It is time for the hearts of the elders to turn to the children. Together we can reimagine the future. Together we can.

 

 

Here is a really helpful film:

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Our Nation’s Biggest Public Health Problem

The subject of this blog is sensitive and difficult. It may stir up some difficult issues or memories for you, as you read. If this happens, then please take time to seek the help you need. I believe this blog and ones to follow might be some of the most important I have written to date.

 

UnknownI am currently reading a phenomenal book, sent to me in the post, by a dear friend of mine, who is a trained counsellor and knowing the work I do, felt that I should read it also. The book is called “The Body Keeps the Score” by the eminent Psychiatrist, Bessel Van Der Kolk. In my humble opinion, it should be compulsory reading for every person training in any of the clinical specialities, including public health and for those working in education. The book focusses on the detailed research and work done by Van Der Kolk and others at Harvard over the last 30 years in the whole area of Complex Post Traumatic Stress Disorder (CPTSD), or “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS). It is not a part of our vocabulary, unfortunately, because even now, after a huge evidence base and many studies, there still remains no such psychiatric diagnosis. However, it is a hidden epidemic affecting huge numbers of our population and is the root of many of our major public health issues. So what causes this problem and just how wide spread is it? The evidence shows so strongly that the cause of CPTSD or DESNOS is Adverse Childhood Experiences, which we more starkly call Child Abuse.

 

Child abuse falls into four main categories: Physical abuse, Sexual Abuse, Verbal Abuse and Emotional abuse – usually in the form of neglect. 10% of children suffer regular verbal abuse. 25% suffer regular physical abuse. 28% of women and 16% of men have suffered sexual abuse. 16% regularly watch domestic violence. 87% of all those who suffer one type of abuse, are also abused in other ways. Each of these forms of abuseUnknown lead to major health problems later in life and studies are showing that it is not just mental health issues (many of which lead to inappropriate diagnoses like Borderline Personality Disorder or Bipolar Disorder and ineffective treatments) but also major physical health problems. Those who have been abused are twice as likely than others to develop cancer and four times as likely to have emphysema. The more difficult a person’s experiences, the higher the chance of developing heart, liver or lung disease at an early earlier age with much higher chances of taking more health risks with smoking, becoming overweight or having multiple sexual partners. There is good evidence to suggest a link with autoimmune diseases, such a lupus, and other complex conditions like chronic pain, chronic fatigue and fibromyalgia. The body cannot be separated from the mind and literally keeps the score of the internalised turmoil. So, even if the abuse happens before memories are formed, or our minds manage to forget or block out what has happened, the body simply cannot forget and sometime and in someway, the damage will show itself. Studies show that the overall cost of this appalling reality far exceed those of cancer or heart disease. In fact, eradicating child abuse would cut depression rates by over 50%, alcoholism by 66% and suicide, IV drug use and domestic violence by 75%. Antidepressants and antipsychotics are now some of our largest prescribing costs. We know this, but are doing very little about it. Perhaps it feels too big. Perhaps we don’t want to face the demons involved. Instead, we are numbing the problem, trying desperately to get people to be just functional enough to keep on serving the needs of our economic system, but we are not facing up to or dealing with this horrific problem, nor its true cost.

 

What can be done in the face of such evil? How can we develop aimages culture of compassion and restorative justice in which we can find a new way through for humanity? It isn’t getting any better. It is just as widespread and far reaching in its consequences as it was a generation ago. Is it possible for us to face up to the startling reality we face? Van der Kolk offers much hope, but it is not within the gift of the health service and social services to tackle this alone. If we are to take this issue seriously, we must embrace what Bessel refers to (at the end of chapter 2) as four fundamental truths:

 

  1. Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing.
  2. Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know and to find a common sense of meaning.
  3. We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through simple activities such as breathing, moving and touching – (learning to be present in our own bodies is a vital way of separating out the memories of the past which can overwhelm us at times).
  4. We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

images-1People can be healed of trauma. We need this at both an individual and corporate level. We have become so focussed on saving money, on quick fixes to ensure the NHS and Social Care System can survive, but we are ignoring the root cause of many of our ill health issues. If we are willing to face up to the truth of child abuse in our society and its long lasting and far reaching impact on overall health and wellbeing, then we might just be able to find a way through to healing and restoration of what has become an extremely broken society. In the blogs that follow, I will look at some of the ways we might find a way through this crisis of epidemic proportions. One thing we must face straight away is that we are spending our resources in the wrong places and are focussing our attention in the wrong areas. We must protect our children and help people learn how to be good parents. We must strengthen our school teachers and sense of community. We must invest in the first five years of life far more than we are doing so currently, especially those key first 12 months of bonding and attachment. Together, if we want to, with love, care, bravery and determination, we can change the future. There is hope. There is healing. Our systems are not yet designed to cope with this, but we must speak the unspeakable, break the silence and face up to the truth. The truth will set us free and enable us to develop the kind of wellbeing that every human being should be able to live within.

 

 

 

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