Routine enquiry into adverse experiences in childhood (REACh)

I was lucky enough (and well enough) to attend a Public Health England event this week about routinely enquiring about adversity in childhood (REACh) .  The importance of this is due to the links with an increased risk of poor mental and physical health later in life as well as the fact adverse events in childhood (ACEs) are rarely talked about until many years after they have happened. The hope is that if ACEs are identified earlier, appropriate support is more likely to be given earlier in people’s lives, especially during times when the brain is thought to be more receptive to change eg. adolescence. The approach is informed by the biology of the developing brain as well the psychological and social effects of these experiences. Some significant improvements in public health were presented by the speakers as potential benefits of this approach.

Most of the factual information, background and evaluation of REACh in Lancashire is in the presentation slides so I won’t repeat it all here. I just wanted to reflect on the day and keep some helpful links for myself but thought I’d put it here in case it was of interest to anyone else.

The questions 

I found the questions themselves validating as crucially they don’t ask you to make a judgement about how bad something was, only whether you experienced it. I found my ACE score reinforced my ability to understand and be compassionate towards myself. The score needs to be combined with your resilience score (at the end of the previous link) to put it in context and it helped to fit this structure around my understanding of myself.

I did think and (others also suggested) that maybe there needs to be a question relating to feeling “like an outsider” or “not connected” to the wider community to take into account experiences of racist abuse, abuse related to appearance or other types of bullying.

I would like to see something relating to chronic physical pain/ill health as a child in there. It’s not interpersonal trauma, betrayal or loss of trust, but it’s a chronic stressor on a young brain and it’s also not hard to see how a child who can’t concentrate, or sleep or complains a lot about being pain may be at higher risk of abuse, neglect, invalidating experiences or bullying, especially where these may be due to medically unexplained symptoms or under-recognised diseases.

Finally, an area that I would like to see included is responsibility for others as a child. Young carers may have specific difficulties that may also lead to increased risk of poor future health.

– edited 27th Feb 2016 to add:

I’d actually like to see a broadening of a lot of the questions especially as we want to capture as much as possible in a short questionnaire.

Eg. Domestic violence may be more likely to be aimed at the mother/stepmum, but there is no reason to specify which parent/guardian the violence is aimed at, unless I am missing something? That’s assuming that we aren’t relying on these specific responses to keep tabs on the statistics on gender-based violence towards women in the UK.

Do we need to specify why your parent can’t care for you or take you to the doctors? Is it necessary for this to be due to substance misuse if there’s already a question about this? What if your parent can’t care for you because they are depressed, or physically incapacitated?

Is REACh new?

I noticed a couple of niggling thoughts- don’t we already know this? and having spent a few years being involved with third sector services, such as the Rape & Sexual Violence Projectdon’t we already do this? 

Most of the ACE research in a general population has been conducted in the USA and this study in 2014 was the first time an ACE study had been done in the UK. It seemed like a critical mass of evidence (including health economic work) had been reached that was winning over more and more professionals. I also learned that in the speakers’ experiences of training staff, many people actually are not ACE aware or don’t know the full scale of the potential long-term effects of them.

Currently we ask targeted questions in targeted services. We don’t ask everyone accessing all health and care services a consistently broad set of questions about childhood adversity when doing psycho-social assessments. And importantly, we don’t routinely train all staff in a service to be “ACE aware”. In my experience, many charities and NHS mental health clinical staff have done this routinely for a long time but many other more general services don’t do this in a consistent way.

So although the idea itself isn’t new, the evidence in addition to the real-life example in Lancashire could mean that sustainable change is more likely now than it has been before. It also felt more like a movement than a straight forward top-down policy, a cultural shift, with everyone involved. The public, cleaners, security guards, receptionists, police are all a part of the approach – to understand, rather than implement a specific intervention or new programme. A real emphasis on changing hearts and minds was made.

I feel that ACE awareness can only be a good thing – in my experience, the culture of an organisation makes a big and very tangible difference to how safe and welcoming it feels. In a setting that is not a mental health specialist service, such as A&E, I can see how having ACE-aware security guards or receptionists may have a positive impact on the response to people suffering and especially to those expressing it in ways that staff may find difficult to understand.

It doesn’t provide any specific “solutions”, but it allows hard-working, caring staff the space, time and permission to really understand themselves and others. It asks them to take notice, in a consistent and open way, of the effects of childhood experiences and the person in front of them as a whole. The specific solutions to problems caused by ACEs will likely come from the staff if informed and nurtured by an environment where this approach is used.

All this has long been more likely in smaller, more dynamic charities and social enterprises, where person-centred care is less constrained by bureaucracy. The innovation here then is the addressing of the specific barriers that exist in the NHS and other services, such as the fears around storing and sharing of this information.

A few thoughts to finish on

A lot of very interesting discussions occurred but my brain hasn’t managed to retain much of it! I hope it will all feedback into the process of taking this forward. And I hope there are sufficient resources put into this to make it happen. I had a few thoughts so I’ve included them below.

The name!  “ACEs” sound so distanced from the trauma they describe and also inappropriately positive. Can you call the rape of a child an “ACE”? I don’t know, but as trauma survivors tend to minimise traumatic experiences, and we are asking people to share things that they may never have done before, maybe it’s helpful to have an academic/less-emotional sounding term for it? And it would seem the research so far done in the UK hasn’t resulted in any complaints. The term is already used across many different sectors, so it does seem to help bring all the agencies together around a common purpose. Maybe the impact will turn out to be much more important than the terminology?

Opening the flood-gates I asked about the fact that they didn’t see an increase in demand for services after asking these questions during the study. I was worried that this was just within the NHS and that the local third sector was put under pressure as a result. It seems this didn’t happen in Lancashire, but it is a potential danger in other places. I hope that any specialist services which experience increase in demand as a result of any routine questioning will be strengthened and supported.

Resilience It was refreshing to hear that the public health approach to resilience has its emphasis on the environmental factors involved in resilience. So often I have heard it implied that resilience is a property of a person’s character. And that somehow we should be able to withstand any hardship or change.  This is very encouraging as it’s easy to feel like maybe you aren’t strong enough, when factors beyond your control have some bearing on your vulnerability to mental health problems. I was pleased to see the inclusion of resilience as a property of the local community, government policy and other external factors. However I never feel “resilience” hits the right note for me. Yes, it’s about bouncing back from adversity, but the courage you need to be “resilient” is not only about “strength” in the common usage of the word. It’s also about the courage to face your feelings and your vulnerabilities and it’s about compassion for yourself and for others. I am not sure if “resilience” always triggers those associations.

Physical health A lot of the talk about physical health was about how trauma can increase circulating stress hormones and have physiologically detrimental effects. While this is important, I wanted to point out that the reverse is also true, that physical pain can make mental health worse, especially if we are told “there is nothing wrong with us”. I think there is a danger that the focus on ACEs may reinforce the dismissal of physical symptoms as psychogenic in people with mental health problems.

Does it have legs?

What really made me feel REACh could be a game-changer was that during training the staff themselves became aware of their own experiences of childhood adversity (which they had previously dismissed, or not noticed) and that of their colleagues. This seems to me to open the doors to compassion, relationships and humanness in what can be a very stressful and rule-filled environment.  It allows people who care for vulnerable people to show themselves compassion and care, which has a positive impact on their morale and work. It makes the whole thing seem like it has the potential to be “contagious”.  It also fits really nicely with my favourite model of trauma – the compassionate mind, which revolutionised my approach to my own mental health the first time I read about it.

I met a lot of very passionate, caring people with an interest in trauma from many different angles – school nurses, writers, therapists to name but a few. There was a lot of energy in that room that day and I’d very much like it to continue and grow. Maybe I was being especially optimistic that day, but it all seemed very promising to me.

There is a network online for those who work in a related area, a website for the general public and  #ACEaware on twitter if you want to join in.