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So the first part the program is about new evidence linking to important public
health topics and this is a new bit of research looking at the relationship
between childhood socioeconomic position and ACES "Adverse Childhood
Experiences" and because this is new research the presentation is kind of
set up in a traditional research type format in terms of background aims and
methods and all the rest, but I know a lot of you if not the majority are not
researchers per se, so I'll try and translate this to non-research-speak
or even English. So in terms of the background I'll just explain what ACES
are and why the topic matters and that'll be familiar to a whole load of
you so I'll skip through it really quickly.
The aims were about what's been missing from this discussion around ACES
and what we were trying to do to fill that gap. The work was a systematic
review of the evidence of the literature and in my experience people who are
excited by the methods of a systematic review are A very small number and B
don't go out very much, so I'm gonna skip over the details of that and instead just
focus on the results which is about what does the evidence actually show, and
that's important because we're trying to use evidence to ultimately influence
policy, and so the conclusions are about what is this evidence mean for policy
why does all this really matter. So in terms of the background then you'll all
be very aware that there's been loads and loads of research over a long period
time linking different aspects of childhood adversity to an increased risk
of all sorts of basically crap outcomes later in life and in recent times a lot
of that evidence has been particularly influenced by a large program of work in
America which was kicked off by a study in 1998 by "Felitti et al" who kind of, sort
of, but not really, coined the term Adverse Childhood Experiences "ACEs" to
capture the the kind of multiple aspects of this type of adversity... and the
definition that they now use for that is now cited as a kind of standard definition
and it comprises child abuse, in terms of physical
sexual or emotional; child neglect physical and emotional; and then a
broader set of factors that they refer to ... I think a bit unhelpfully, as
aspects of household dysfunction. So that involves living in a house where
somebody has poor mental health or where somebody's been put in jail or where
there's domestic abuse, substance abuse or living through parental separation or
divorce. And although it's put forward as a standard definition
actually what came through from this review is that there's no such thing.
There's a complete lack of any consistency in terms of how ACEs are
measured across different studies... and that's a very problematic and I'll come
back to that at the end. But no matter how they're measured, as I say there's
lots of evidence associating this type of adversity with a whole range of
adverse outcomes, and this includes risk of premature mortality and also
risk of a whole set of diseases of which these are only a subset. And it's a
graded relationship... so in other words the the greater number of adversities in
childhood then the greater the risk of experiencing these adverse outcomes. So
because of that it has become a major focus of policy in lots of different places.
People always talk about Wales which isn't something that often happens
in my experience, but there's lots of things been happening in Wales with
regard to ACEs and policy and practice. ACEs have been emphasised at
UK Government level in terms of lots of parliamentary committees and the like, and
of course here in Scotland they're very clearly an important priority for
the Scottish Government. So if for example you look at the 2018-19 program for
Government, the legislative program for the Scottish Parliament, ACEs are woven
throughout that document under all sorts of different policy topic headings.
There's a real emphasis on the need to try and tackle childhood adversity. And on
the front cover there you see wee Nicola looking all chuffed that she's
found somebody smaller than herself, [laughter] with which to pose for the photograph and
actually I saw Nicola Sturgeon speak at the screening of this American film on
ACEs, called "Resilience", and she spoke very passionately from the heart
about what massively important topic this is, and it is an incredibly
important topic, addressing childhood adversity. At the same time there seems
to be a kind of movement in Scotland around making the country quote "the
world's first ACE-Aware nation" and there was a conference last September, I
think this might be another one coming up again, at which literally thousands of
people assembled, both at the Armadillo and also a Hamden Park... and you could
pay between a hundred pounds for the cheap seats and 150 pounds for the not so
cheap seats to hear a one of the stars of that film speak and a whole range of
other presenters... and if you went to that conference or if you went to the
screening of that film, that I did, you'd be inundated by all sorts of different
publicity material for toolkits, training courses, awareness raising
sessions all around ACEs... and I think you can interpret this all in one of two
ways. Either a set of helpful resources with which to help in bed ACEs awareness
in society or as an industry cashing in on a fashionable phenomenon. I chose my
words carefully there. I'm not interpreting them in either way.. I'm
leaving up to you. But the real point of putting that up is, if you read
through all that material or if you go and watch that film or you read through
a lot of these policy documents, although they focus on ACEs, on adversity they
don't really say very much about the likely influences on ACEs, which is about
poverty and broader socio-economic factors. That's kind of all missing from
the discussion. Which in the one hand maybe that's okay, because ACEs aren't
just about poverty and childhood adversity has seen across different social classes
and indeed that first American study that I mentioned was actually based on a
very skewed sample of white middle-class Americans and it still shows an
association with all sorts of outcomes, adverse outcomes. But on the other hand
if you go back to that definition, it's still called standard definition of ACEs, all
the components of it are very clearly socially patterned. So I'll show you evidence in
a second of the social patterning of abuse and neglect and then if you look
at things under this heading of household dysfunction, well we know
that poor mental health is massively socially patterned, higher
prevalence rates among the poorer for obvious reasons. The same is true of
incarceration rates, of domestic abuse, of substance abuse, be that around alcohol
or be that around drugs, and it's also true in relation to
separation and divorce rates all linked to socio-economic related
stresses. So that obviously begs a question. In all this huge discussion around ACEs and
this policy focused on ACEs, what is actually the role of childhood
socio-economic position or poverty in understanding and importantly addressing
them... and so from a researcher point of view then the question is what's the
actual evidence. So this was the aim of this bit of work, to review and
synthesise the evidence the research literature on this relationship between
childhood socio-economic position and ACEs. Then some of you may know there's
different ways of doing that; different ways of reviewing the literature. By far
the best way is a systematic review. So that's whereby two or more (in this case
three reviewers) independently screen all relevant publications on the topic and
then extract all relevant data from that. It's the best way of doing it; it's
also by far the most painful way of doing it; and as I've said in presenting
this previously, this whole project has been as enjoyable as chewing off
your own toes. But anyway that's a different issue. So we were searching for
studies which mentioned ACEs or a whole range of synonyms and SEP or a whole
range of other similar terms, but the only bit the methods I really want to draw
your attention to is that we were looking specifically for studies which
included a childhood measure of SEP, for obvious reasons, and where ACEs where
the outcome. So in other words we weren't interested in the many studies where
ACEs predict an outcome, but rather were looking at what predicts ACEs. We
only were searching back to 1998 because that's when that American study
first came out and we used a particular way of assessing the quality of studies
and the risk of bias, and I'm not going to bore you with all those details. So in
terms of the results. If you've ever sat through the presentation of the results
of a systematic review and stayed awake, then A congratulations and B you might
know that they're usually presented in this kind of standard way; this is a
flowchart which summarises the searches, how many studies were found, included
excluded and all the rest. And I'm not going to bore you with the details but
the headline is that if you search for studies which mention ACEs there are
thousands and thousands and thousands of them. If you search for studies which mention
ACEs and some kinda measure of socioeconomic position, then you have
to, as we did, look at around about 3,000 studies. The important question is how
many of those studies actually looked at the relationship between childhood SEP
and ACEs and the answer is six! There's really not very much out there at all
and I wouldn't bore you with the rest of the details. But when we were doing that
it became apparent there actually was a bigger literature looking at the the
link between poverty and, not ACEs, but child maltreatment. Now obviously there
are important differences between that much more specific issue of maltreatment
and that much broader definition of adversity. But again if we go back to the
so-called standard definition of ACEs maltreatment is a huge component of it,
because the definition of maltreatment is actually child abuse and neglect. So
in this definition that accounts for five of the ten ACEs. So it seemed important not
to disregard that but to include it in the searches. So joyfully we had to
do all the searches again; this time looking not just for studies mentioning
childhood SEP and ACEs, but childhood SEP and ACEs or maltreatment. And that
meant that we had to look at about four and a half thousand papers; again joy
unconfined, of which thirty five satisfied the inclusion criteria. Which
isn't great but it's better than six... and gave us something to look at. Again I
won't bore you with the rest of the details other than saying that one of
the aims of a systematic review is to do some kind of meta analysis... that's where
you pull together all the results of all the studies and trying and calculate a
kind of overall effect size; in this case the overall effect of
childhood SEP predicting ACEs. We couldn't do that this time
basically because of what I referred to earlier: the incredible inconsistency in
terms of how ACEs are measured. They just vary in so many different ways.
Measures of SEP also vary in a hundred different ways too and the age at which
adversity is measured is an important factor and that changes all the time
across different studies too. We've obviously ended up with a relatively small number of
papers and just by the by about half of those were categorised as high quality
papers. But despite those two limitations what emerged from the available evidence
is the fact that the association between childhood SEP and these different
measures of childhood adversity is very very clear.
So there are meaningful, statistically significant associations.
Seen in just about all the studies including just about all of those deemed
to be high-quality. I'll just flash up a handful of them now just to give you
a flavour of what the research has shown. So for example (I don't know how legible
any of this will be, but don't worry I'll talk you through it) This is a study
looking at a fairly large Brazilian birth cohort and they looked at the risk
factors for experiencing ACEs and showed the children in the poorest
households were about two and a half times more likely to experience four or
more ACEs compared to those in the least pure households... and children classed low
SEP in terms of maternal education were about six times more likely to
experience four or more ACEs compared to those of higher SEP. An American study
and again don't worry about the legibility. It looked at the so-called standard ten
ACEs and how they related to other factors which included whether or not
children were born and raised in families where there was frequent family
financial problems and they showed those in that category were associated with an
average seven of the ten other ACEs... showing again the clear association
between the two. And cheating just a little bit because actually the study
came out just after we'd run the searches but because it's based and
Scottish data I've included it... and this is based on the "Growing up in Scotland"
study which as you may know is a larger representative longitudinal birth
cohort and that showed that Scottish children in the poorest
households are about twelve times more likely to experience three or more ACEs
at age eight compared to those in the least poor
households. And in terms of the maltreatment searches, again just a couple
of very quick examples, this was a study from Australia which looked at economic
risk factors for experiencing maltreatment and the
definition of maltreatment actually included witnessing domestic violence, so
it's a broader definition, a bit more likely ACEs definition, and showed a
clear association between a whole range of different economic risk factors including
being brought up in poverty. This is a Dutch study, which is a little bit
complicated, and collected data from different sources, but the headline is
that children in low SEP households defined by parental education were at
about nine times more likely to experience maltreatment than those
in high a SEP households and children in poorer households defined by parental
unemployment... about six times more likely to experience maltreatment. And the very
last example is from a huge study in Australia which looked at all children
born in Western Australia over a 15 year period and among non-Aboriginal children
showed that those born in the most disadvantaged circumstances were about
fourteen times more likely to experience maltreatment compared to those born in
the least disadvantaged circumstances... and I could go on and on and on and I
frequently do but basically from the existing evidence what emerges is a very
clear relationship between socio-economic position in childhood
and the risk of experiencing this type of adversity. And this relationship is
robust across countries, the many different measures of SEP and of
adversity, and at the age at which adversity is measured. But there's a lot
more research into maltreatment and I think importantly that suggests that
in these big discussions around ACEs, childhood SEP or poverty is not
integrated into the understanding of what causes them. I think that's an
important point and it's one that's also been echoed by other people in terms of
this decontextualised manner in which ACEs are being discussed and that's true
both of policy and also as I've just shown you in terms of research and there
was a really nice paper which you will be able to read, which came out
this year from Michelle Kelly-Irving and Cyrille Delpierre who looked at the quite
dramatic increase in the amount of research into ACEs in recent years; these
are publications by a year and they attribute this increase to a whole
range of different factors most of which they criticise
pretty heavily and suggest that such a sudden increase in this topic may have
contributed to the decontextualisation of ACEs from the wider socio-economic
landscape and to a mismatch regarding links with policy. Which is
quite a neat summary of basically what our study is also showing. Is there also
decontextualisation of this type with regard to child maltreatment... well not so
much but the importance of poverty is much more clearly expressed in the
American literature for some reason and not so much in the UK literature. And
that is reflected also in a really nice review by the Joseph Rowntree Foundation
from just a few years ago, who again highlighted the amount of American
research into this, in comparison to the very limited evidence base in the UK, and
indeed suggested that in the UK there's a lack of joined up thinking and action
about poverty and child abuse and neglect
and child abuse and neglect as I said is the definition of maltreatment. So and
just before I shut up, the main points to know are that this association between
childhood SEP or poverty or whatever you want to call it and ACEs is very, very
clear but also very clearly under researched. The policy focused on helping
people who have been affected by Childhood Adversity is clearly a very, very, very
good thing. But at the same time ignoring the wider socio-economic context to it
is a very, very stupid thing. And just to hammer home the point and you
all know that in this wealthy country of ours, currently in excess of one in four
children are classed as living in relative poverty, but the Scottish
Government's own projections, based on the effects of UK government austerity
measures and welfare reform and all the rest, is that in a few years we'll have
around about 40 percent of children in this category. And this figures actually
a bit lower than elsewhere in the UK. But if we don't do something about this
we'll never do anything about child adversity because of the association
between the two of them. So policy obviously has to do both to help those
currently affected but also to prevent further adversity it has to address the
key socio-economic drivers of it. And I would reckon that most people in this
room think that's quite an obvious point but the issue is that there's a lot of
people work in this area to whom it's not an obvious point
and at that point I'll stop talking thanks for your time.
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