The ACE’s Framework

The findings from the Adverse Childhood Experiences (ACEs) research are now well known. Dan Johnson explores what we can do about it.

The ACE’s framework

I’m guessing you know about the ACE’s research by now (if not please read the blog or paper by CYCJ’s Nina Vaswani!). The ACE’s framework has become a popular and powerful way of explaining some of our most concerning social problems.

The science isn’t perfect but it’s hard to argue with the core message: adversity in childhood can make difficulties in adulthood more likely.

Recent and robust research continues to find this.

So what to do?

There are two main implications. First, we need to prevent adversity and harm for children. This is not new and child protection has been an important movement in the UK for many years. There is always room to improve though and the ACEs research provides another impetus for this.

The second implication is that we need to do something helpful for those children and adults who have already experienced adversity. The difficult bit is working out what that should be.

Humour me for a moment and ask yourself a question before reading on: what is the common response of services when faced with children from high adversity and who have extremely concerning behaviour? What would professionals think was needed?

There are many answers to that question but figures about referrals to Child and Adolescent Mental Health services (CAMHS) suggest that a referral to CAMHS  is a common response. There are frequent stories about under-resourced CAMH services and the increasing demand for therapies for young people.

Now, it is important to acknowledge that CAMHS and psychotherapy can be an important and sometimes essential part of a helpful response but we also need to be realistic about what they can achieve.

For example, therapy is dependent upon someone choosing to attend. Ask yourself how many of the young people you know who have experienced high levels of adversity are genuinely motivated to attend therapy? And of those, who are able to engage meaningfully and implement skills outside of sessions? And in turn, how many are able or willing to explore their adverse life experiences as part of trauma-focused therapy?

There are some young people who fit each of these questions but unfortunately it is unlikely to be the majority. The frustrating thing is that some of the core effects of adversity and trauma can be mistrust, hostility, aggression and chaotic lives- all powerful barriers to meaningful therapy. Skilled therapists can do much to overcome these but it takes time and relies on the willingness of young people to meet them in the first place.

All this doesn’t mean that therapy shouldn’t be attempted. It can still be extremely helpful, it just means we need to be realistic about what it can achieve for all.

What all of us can do

Trauma Informed care (TIC) has become a catch-all term to describe practice or services that aim to somehow fill this gap. The idea is that instead of one specific service being responsible for sorting all this out, everyone becomes informed about trauma and adversity and is therefore part of an effective response to it. It is not just up to the therapy service. Amongst others, the school, the social work department, the care home and the police are part of an effective response.

There are many definitions of Trauma-informed services but the USA’s Substance Abuse and Mental Health Services Administration (SAMHSA) definition is often used. This states that a trauma informed service is one that:

  1. Realizes the widespread impact of trauma and understands potential paths for recovery;
  2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
  3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
  4. Seeks to actively resist re-traumatization

How do you actually do trauma-informed practice?

SAMHSA states “a trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures.

  1. Safety
  2. Trustworthiness and Transparency
  3. Peer support
  4. Collaboration and mutuality
  5. Empowerment, voice and choice
  6. Cultural, Historical, and Gender Issues”

The hope is that when a service or person aligns their practice to these principles, they will in some way be part of a helpful response and perhaps even undo some of the harm caused by adversity and trauma. Explaining the reasoning for each principle would take up more than a blog post but the core of the idea is that essentially, services provide the opposite to trauma and adversity. By doing so, the hope is that those in contact with them may feel able to undo the counter-productive adaptations they have developed in response to adversity. An example may be someone that has grown up believing that in order to keep themselves safe they need to keep everyone away by any means, including violence. If subsequently, the services they work with continually provide safety, then perhaps they could eventually leave this strategy and allow others to get close.

Sounds good but does it actually make a difference?

The seasoned veterans of child and youth work might feel their cynicism kicking in at this point, wondering if this is the next fashion that we’ll have forgotten about in a few years. This is understandable as it has some of the hallmarks of a fad: it has come over from America, is often shortened to the three letter acronym “TIC” and is a buzzword that managers seem to drop at meetings!

Encouragingly, there is evidence that trauma-informed approaches can be helpful and effective at improving services, as long as the services adhere to the core principles and good implementation strategies. The outcomes seem positive but we need to avoid raising expectations too high. Trauma-informed approaches are not going to be the panacea we want them to be but they could make an important shift in the right direction.

So where can you start?

There are some great online resources for implementing trauma informed care: trauma informed Oregon is a good place to start. If a large scale implementation plan is overwhelming then some brief self-evaluation can be very helpful. See here, here and here for some different tools that might be useful. In the spirit of trauma informed values, these are likely to be most useful and helpful if they heavily involve the children and young people who the service is for.

Another good starting point is to learn more about trauma theory and practice. There are many great resources including the National Child Traumatic Stress Network. In fact the choice can almost be too much, so a good place to start planning what you need to know is a very useful knowledge and skills framework put together by NHS Scotland. This specifies what knowledge and skills people should have, depending upon their role, ranging from those with limited contact with service users to the specialist trauma clinician. There’s also a growing online community who are discussing and exploring ACE’s, trauma informed approaches and implementation.

Good luck and please share any experiences after you begin to be trauma informed!

All thoughts welcome

About our blogger

Dan Johnson is Senior Forensic Psychologist at Kibble Education and Care Centre

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