Adverse Childhood Experiences: What they tell us and implications for social care

[Introduction] 

This is a Research in Practice podcast supporting evidence-informed practice with children and families, young people and adults.  

Fidelma: So, hello everyone and welcome to this podcast for Research in Practice. I'm delighted to welcome today Dr Kirsten Asmussen who is Head of What Works, Child Development at the Early Intervention Foundation (EIF) and is also lead author of a recent EIF report entitled ‘Adverse childhood experiences: What we know, what we don't know and what should happen next’. In this podcast, we'll be taking a look at ACEs (Adverse Childhood Experiences) and with Kirsten's expertise deepening our understanding of what we do and what we do not know about ACEs and the implications for public health and social care. So, Kirsten, I know amongst our partners at Research in Practice, ACEs has become quite a hot topic. Lots of people are asking questions about it and trying to understand what the implications are for their own organisations and practice but maybe we could start by just thinking about from your side at the Early Intervention Foundation, what prompted you to look into ACEs further and what promoted you to write this report?  

[Why did the EIF decide to look into ACEs and write the report ‘Adverse childhood experiences: What we know, what we don't know and what should happen next’?] 

Kirsten: Well, as the title of our organisation suggests, we are about early intervention and that means stopping things from getting worse at any point in a child's life, so it might mean preventing things and it also might mean treating things. It is quite encompassing and the concept of adverse childhood experiences (ACEs) has been around for about twenty or so years now and when we were set up in 2013, it was one of the reasons why we were set up, it was part of the business case that these things existed and that they were potentially preventable and treatable and so that was one of the things that we were supposed to be seen to be doing. However, in the first years of being set up, we were looking at a variety of different activities that could improve children's lives including supporting the home learning environment, supporting their social and emotional development, etc., so we had thought about ACEs but not in the depth that we had hoped. At the end of 2017, UK Science and Technology Committee announced that there was going to be an investigation or hearing into adverse childhood experiences and the role that really intervention could play in preventing and treating them, so all of a sudden we found ourselves saying, 'Well, we need to have something sensible to say about this.' I mean, we had some rough idea but we need to put together our thoughts.  

So, we put together a testimony and we went and spoke and such but we felt, you know, that it wasn't as deep as we would've liked it to be, that we needed an organisational position on it. We understood that the evidence in this area is actually quite controversial in some respects but, even more so, some of the practices that have followed. So, there is not a straight clear forward evidence-based answer, at least not that we were aware of at the time. So, we decided that we were going to do a very comprehensive narrative literature review in all aspects of the ACEs narrative, starting out with the, you know, the framework that was put together in the original ACEs study. Then also in terms of, for example, the evidence underpinning the brain science of ACEs and then also what evidence existed underneath some ACEs related practices, in particular, screening, population screening for ACEs and also trauma-informed care. So, we did this really partly to improve our own knowledge of ACEs and also, as one of our advisory group members suggested, that we wanted to help our audiences become better consumers of the ACEs evidence. That meant breathe a little bit of healthy scepticism into what was out there but not throw the baby out with the bathwater at the same time. So, I hope we achieved that.  

Fidelma: Right, because the last few years, there has been this, kind of, surge in popularity of the ACE narrative in the UK but with that, arguably, have arisen some misconceptions and perhaps misapplications of the ACEs framework. This report, it feels like, is really doing a lot to address what the evidence can and can't tell us, so perhaps we could move on to thinking about what it can and can't tell us. So, I mean, could you actually tell us a little bit more about what we are talking about when we're talking about adverse childhood experiences, to begin with? I guess, our listeners will have a good idea, many of them already but perhaps you have a clear definition that could enlighten the rest of us?  

[Explanation of what is meant by Adverse Childhood Experience (ACEs)] 

Kirsten: Well, there's the traditional definition that was, well, I don't even think they thought of it as a definition at the time but the original ACE study which dates back to 1998, well, it was published then, actually it was conducted before then, looked at ten childhood adversities and considered how they predicted a variety of negative adult outcomes from health records and also adults recollections in terms of the poor outcomes that were ranged from diabetes to cancer to stroke and heart disease and a variety of very serious mental health issues including chronic substance misuse, depression and suicidality. These ten childhood adversities included six forms of abuse and neglect, so these were actually the very traditional categories and the questions that they used to ask them came from the Conflict Tactics Scale which is commonly used to measure the prevalence of abuse and neglect or abusive ways of resolving conflict. So, the questions were about, 'Had you ever been hit before? Had you ever seen a parent hit another parent?' They didn't ask children if they were neglected per se but, you know, 'Have you been hungry for long periods of time?' But all of the six categories are those that would be punishable in many countries by law, so we're not talking about a casual witnessing of people getting cross with each other, we're talking about a parent hitting another one or a parent being incarcerated but, interestingly, parental separation was on that list.  

I should backtrack. So, there were six forms of abuse and neglect and then four forms of family dysfunction and that includes parental separation, parental substance misuse, chronic substance misuse, parental mental illness and a parent who has gone to prison. So, they decided to look at, the original study was to see, you know, did any of these things predict poor adult outcomes? And, we know already in the child protection literature that they do, that's been known for a while but I think that was what was interesting about this study was that they had these additional ones and they felt that they found that there was this cut off of four that seemed to predict them in particular and that in some instances, the relative risk became quite dramatic. So, for example, if you had four or more ACEs, you were at a ten- or more-fold risk of suicidality or intravenous drug use. So, the title of that report then was something along the lines of adverse childhood experiences may be the root cause of many life-threatening diseases, with the idea here that they were actually causal. Even though, if you read the study quite carefully, they don't go quite as far as saying that, they said they found an association between the existence of ACEs and adults' memories of ACEs and then poor adult outcomes later on.  

Fidelma: So, that was the unique contribution of this study? That clearer link between the number of those adverse experiences as a child and risk of those poor adult outcomes? Right, and do we know about how common ACEs are in the population?  

[Prevalence of ACEs in the population] 

Kirsten: That's a good question. In reality, no we don't. We know that somewhere around 2% of children are on the child protection register or are known to local authorities where there is some kind of concern but we also know, we've known historically, we always know that this is really the tip of the iceberg. So, when you look at these retrospective surveys with adults, ACE is one of a number. There was actually a very good prevalence study conducted by the NSPCC about ten years ago now, you start to see that the rates for lifetime prevalence are much higher, anywhere between 10% to 20%, depending on the ACE, certainly, with parental separation, we're looking at around 50%. But, of course, four or more, that is more rare and so we're looking again, sometimes below 10% of the population. I think what's remarkable is that the ACEs studies that have been conducted to date with adults, again, and I should emphasise this is with retrospective recall and we're looking at lifetime prevalence, is showing anywhere between 10% to 20% depending on the ACEs, and then somewhere around 10% for four or more.  

Fidelma: So, given that's what we know and that's what your report was really able to, you know, like, digging, drilling down into the evidence and pinpoint that which we know, but your report also looks at what we don't know. So, some of the points that you've talked about just now, so identifying what those ten original ACEs were from the original Felitti study and that association between increased adverse childhood experiences and poor adult outcomes might make one feel that this is, kind of, deterministic. You know, if you've experienced a lot of adversity in childhood, it's kind of inevitable that you're going to have those poorer outcomes, but can you tell us, can you kind of reign us in a bit and tell us what it is that we don't know and what should we be cautious about when interpreting or extrapolating from those associations?  

[Interpreting risk arising from ACEs] 

Kirsten: Well, I think one way to think about it is just what do we mean by risk and what is the absolute risk of when there is an increased relative risk and how can we interpret findings about risk? I think that this is where-, there wasn't a flaw with the Felitti study, it did what it did, I think it's the interpretation of what it did that is maybe misleading now in terms of this deterministic message because many things that people do create risks in their lives. Smoking is a very common one and yet we all probably have a relative who smoked their entire life and they're still living to be in their 80s. So, relative risk is not always a very good predictor of things on the individual level and the differences in relative risk that Felitti and colleagues found with very rare things that doubling or whatever risk that is was can be somewhat accurate from a population standpoint when you're looking at your population statistics. But when you start looking at relative risk and you're talking about something very common, like cancer, which, I think, is an interesting point that was made in this recent article that was published in the American Journal of Preventative Medicine, you can say, 'Well, it might have doubled that risk but it's not actually a very good metric because a variety of different things can and because cancer is so common, it's predicted by very many things.'  

So, even though the statistics are right, they're not particularly deterministic and, just to give another example, so one of the things the ACE study and subsequent studies have done is they've noticed that four or more ACEs increase the risk of intravenous drug use or opioid drug use by at least 10, but in the original ACE study, I mean, the population generally, it is the prevalence rate is 0.01%, so it increased it in the sample of children who had four, or the sample of adults who had four or more ACEs, it increased it to 1% but that still means that 99% of the people in that sample did not go on to use intravenous drugs. So, I think we need to be very clear about what these deterministic risks mean, that they should maybe, just like if you had other health risks that were very rare, they're known, for example, a variety of genetic problems, we do test for them when a mother's pregnant, even though it's very rare, because we can with some accuracy. But, we also know that even if there might be hereditary risk for something, it doesn't mean that the child is going to be disabled or whatever that you're testing for. So, I think that needs to be borne in mind and, unfortunately, you know, when you look at some of the hubs, the ACE hubs that are out there, you get the message that an individual who has had a very unfortunate childhood is going to go on and repeat that die an early death. In fact, you know, when you look at the population statistics, you will see an increased risk but, certainly, not that level of determinism. And, by and large, for example, children who have been abused do not go on to become abusers in their adulthood and I think that that's something that people should not forget.  

Fidelma: That's really important. Yes, really important to keep in mind and not to have that message overshadowed by what was part of population studies and understanding increased risk but, yes, that's really clear, thank you. What about in terms of the actual ACE categories? Going through that list of the ten categories, you know, it's notable that all of the categories, so the forms of child abuse and neglect and then the forms of family dysfunction that you mentioned, well, they're all to do with the family, aren't they? They're all to do with those, kind of, intimate experiences in relationship within a family. What about other factors? Are they taken into account within research around adverse childhood experiences? So, systemic and structural issues?  

[Associations between ACEs and other factors and outcomes] 

Kirsten: Well, the studies are becoming more sophisticated in doing that but the original ACE study did consider people's education, they controlled for that in the analysis, so that's one way of, kind of, taking it into account but they didn't really explain it. But, just before going into that, it's worth noting that the ACE categories are highly correlated with each other. So, for a child, for example, who experiences physical abuse is much more likely to be psychologically abused as well, so you really find these clusters of behaviour and so the question is are you really measuring ten different things or are you measuring one big thing very chronically, for example? Now, I don't want to go into details about poly-victimisation and how this overlaps with those findings and that there is probably something that this has picked up here that the variety of the different categories is more traumatic and detrimental than just one category, but we know, in fact, that that doesn't happen very often either. So, it would be very rare for a child to be just physically abused and not be psychologically abused as well. So, they're not clean, separate categories to begin with. On top of that, we know that those categories are highly correlated with other adversities, like poverty, like crowded housing, like racial discrimination, like a higher likelihood of being victimised outside of the home.  

So, there's nothing really sacred about those ten in predicting poor outcomes and when you're thinking about preventing something, you want to know what it is that you need to prevent so that you can do it, so you can do it with some precision, and I don't think that the evidence is strong enough to say that some of the poor outcomes are correlated with the ACEs versus other things that coexist with ACEs, such as poverty. The science doesn't appear to be there yet but, for example, many of these physical outcomes that were associated with ACEs are probably better predicted by some of the adversities that coexist with them such as poverty, such as insecurity, for example, such as poor birth outcomes. In fact, we looked at studies, they're in the appendixes of the report but we looked at studies that were showing increases in risk that were comparable to those by four or more ACEs with just one of these other categories. So, for example, poor birth outcome is actually a higher risk of poor adult outcomes than any of the four or more ACE categories, yet that coexists with these other things too, so they didn't pull that apart completely. I feel silly saying these things though because when you make that observation it's like, 'Well, should we not worry about ACEs?' Of course, we should, they are terrible things that happen to children and they should be prevented, many of them are against the law, that shouldn't be the point but when we're starting to talk about causal relationships and using that as to explain certain findings, I think that that's where the interpretation becomes a little bit trickier.  

So, the original ACE study was conducted twenty years ago. It was a retrospective study which there are methodological limitations with that as well because it turns out that adult memories are not particularly good, particularly when you're talking about the number of ACEs to get that level of precision there. So, a better way of looking at this is with prospective cohort studies that track a large population of individuals at regular intervals, starting at the child's birth and then carrying on through adulthood. In those studies, we see a very strong and consistent relationship between ACEs and poor mental health outcomes but it is much weaker, if non-existent, for physical health outcomes. So, we really don't know about that relationship yet and certainly not with the precision that we had thought that we did. Although, there is some evidence that, for example, child neglect might be contributing to poor physical adult outcomes but that's part of what we don't know yet and we need to find out more about it but, right now, I think there are many assumptions that are out there that people will get very ill, they're at much greater risk of having mental health problems, there's no doubt about that but in terms of physical health problems, you know, you see these statistics saying, 'If you got rid of ACEs, you would cut down heart disease by X amount,' I don't think we can make those claims yet.  

Fidelma: I suppose, as you've said, you know, those adverse childhood experiences which, you know, so they're focused on the family relationship and a lot of the categories come under criminal offences and, obviously, they do need our attention. But, I suppose, what you're saying as well is we need to have a fuller picture without also thinking about the wider structural issues that are also associated with poor adult outcomes and which may indeed underpin those family dynamics. So, they seem to be, from what you're saying, they're associated, so things like poverty and crowded housing and higher levels of parental stress, that, you know, we shouldn't be completely distracted away from also thinking about those wider underpinning issues?  

Kirsten: No, we shouldn't. In fact, again, in the appendix in the report, we review evidence that's looked at studies by and large conducted in North America but where they've actually given people, they've moved them into completely new neighbourhoods or they've looked at changes in family interactions once parents either received benefits or were put into employment and you see dramatic reductions in violent interactions with each other. You know, we know that poverty is a serious and chronic cause of stress and that people, when under stress, that stress spills over. That, of course, shouldn't say that if you're poor, for example, that you're going to be abusive to each other, that doesn't mean that either. It's just, again, a risk factor. It also doesn't mean that there are some individuals where poverty isn't an issue and yet they're very poor at resolving conflict and do abusive things to each other so, you know, again, looking for causality in these things, it's not as simple. You know, many times these things are multi-determined and we need to recognise that. It's not one clear answer, so it's not just poverty but poverty shouldn't be forgotten either and I think that that was one of the things that surprised us when we looked at the ACEs study is that very few of them either controlled for it or they considered the role of, the impact of poverty on the likelihood of the ACEs. Very few studies that did actually found that, sometimes, poverty was a better predictor of some poor adult outcomes than the ACEs themselves.  

Fidelma: That's really interesting because there is a danger of a heavy focus on the individual and the family nexus, that, kind of, over-responsibilise (sic) families and ignore those other structural elements so, yes, that's helpful to bear in mind when thinking about ACEs.  

Kirsten: Just to sum up, in terms of what we don't know is that ACEs, the relationship between ACEs and physical adult outcomes is fairly tenuous. I think we can say with increasing confidence, however, that ACEs are linked to poor mental health outcomes and they are also, this was originally observed in the Felitti study that ACEs are associated with a greater likelihood of a variety of health-harming behaviours that includes harmful drinking, risky sexual behaviour, smoking, overeating. Now, the question is again, is it the ACEs that are causing that? That was the hypothesis in the article or do those behaviours happen at a family level alongside ACEs? So, for example, you know, if a parent drinks heavily and children will learn that behaviour from the parent as well, so it's difficult to understand the relationship. We don't know for sure but we do know that ACEs increase the likelihood of these health-harming behaviours. But, I think this is something that was important for us is that we also know that there are a number of things that you can do with children, and particularly young people, to prevent them from engaging in these behaviours before they've started them, even when they're living in average circumstances. So, we think that those sorts of behaviours could be addressed through the use of evidence-based interventions.  

[Implications for social care – the pitfalls of screening for ACEs] 

Fidelma: Okay, well, let's maybe move on to thinking about, kind of, the implications for social care, if that's okay? Because I know that will be something at the forefront of many of our listeners' minds, you know, what does this mean for them? So, I know you mentioned the recent, I think it was March 2020, a paper in the American Journal of Preventative Medicine and it's interesting that, so, you know, in the original Felitti study, the ACE categories were used to understand the association between adverse experiences and adult outcomes, others have gone on to take those categories and use them within screening programmes within public health. So, coming up with an ACE does count for individuals coming into contact with public health, but this paper that you referred to earlier in the American Journal of Preventative Medicine, which was written by some of the authors of the original study, stated that, in fact, using the ACE scoring in that way, to quote, ‘isn't suitable for screening individuals and assigning risk for us in decision making about the need for services or a treatment’. But we do see that routine ACE screening is increasingly popular as a frontline response to ACEs, so can you enlighten us around routine ACE screening and what does the evidence related to screening suggest?  

Kirsten: Well, I think, that when we embarked on the report that this practice was the most surprising for us because normally the tests that have to take place for population-wide screening to be implemented are quite substantial. So, for example, if you think about the Edinburgh Postnatal Depression Scale, it has been tested in almost every single country in the world for its sensitivity and specificity and by that, we mean when people fill this thing out or when they're asked the questions on that scale, are they predictive of them having a serious mental health problem or a serious issue with depression? And they used other measures to verify that as well as, you know, just interviews with people about their experiences and how it's impacting their life. So, it's been tested over and over and over again and whilst we wouldn't even call something like the ACE questions a screener, they were just in a survey. They were survey questions and they found a relationship, but it was never developed as a screener or a diagnostic tool and people never had tested to see how four or more ACEs predicted outcomes at an individual level. So, as I just illustrated before, for example, four or more ACEs increases the risk of intravenous drug use by, you know, tenfold. But, on the other hand, it's still going to be quite difficult to use that count to predict it on the individual level, whereas something like the Edinburgh Postnatal Depression Score predicts this at 80% or higher depending on the population.  

Some populations, the screener is around 90% and these are the standards that we have for the kinds of measures that we use for population screening, so I think, for us, it was quite surprising that this counting was taking place without any of this testing having occurred in the past. The point that they make in the article, which is also very valid, is that when you're looking at population-wide trends, those counts are good enough. You're predicting things happening in a population and you want to know what percentage of your population might be having these problems and that's really important for planning services, that's vital. But, it's not something you would use to predict something on the individual level, so it's a bit of a mix up to use this very crude instrument to make predictions at the individual level and the risk there is that if you're relying on it, you will identify children needing more help who don't need it at all, and you will miss children who desperately need help because experience of ACEs, even though it might overlap with symptoms of trauma or problems, is not the same. So, you could have one ACE but it could be so traumatic that you could desperately need help. So, for example, there are many children whose parents have maybe, the only thing that's happened to them is a very difficult family separation, going through divorce. Otherwise, they wouldn't have ticked any of the other boxes but they could still need quite a bit of help.  

Fidelma: Right, because there's no nuance within the questions, is there? It's not about, kind of, how many times a particular ACE category was experienced or even the example of separation and divorce, I think is a good example what that experience meant to the individual, it's just whether it occurred or not ever.  

Kirsten: Right, so, obviously, there is a correlation between the number of ACEs and the risk of trauma. And trauma, quite often people mean things like PTSD (Post-traumatic stress disorder) but they're looking at and defining it in other ways. Some people actually count ACEs or talk about ACEs as trauma, where we know that it's not. That's not to say that, certainly, individuals who have had a very difficult childhood with a high level of ACEs probably are at greater risk, I think that that's fair enough to say but you wouldn't use it as a diagnostic tool. It would be overly reductionist if you did that. But, I think the thing that bothered us the most when we started doing this research is there was an assumption that people don't mind asking the questions and, in fact, if you ask them the ACEs question, just being able to talk about it for the first time is kind of a watershed moment in that they will naturally seek help on their own. In fact, most of it has not been rigorously evaluated yet. But, over the last several years, in the last two years, there have been studies looking at the acceptability of this, and what's interesting about it is that, you know, as most studies, they don't recruit everybody that they should at the study but these studies in particular, the individuals that they spoke about, whether or not they liked the questions, tended to be the ones who weren't experiencing ACEs and the most vulnerable did not participate in the study.  

There was one study that has been published in the last couple of years that did look at this and found that the most vulnerable families were the most uncomfortable answering those questions and were the least likely to answer them truthfully. So, you know, if that's the case, then it's not going to work at all is it now? It's going to stigmatise people and I can also imagine situations that if you wanted to get something out of something, you could exaggerate it as well too as say, you know, 'I've had all this bad experience in my past and so that explains it,' and, you know, just somehow get off the hook of something. So, I don't think it's a, from what we can tell right now, it's not been studied enough to be used at population level or even with a practice, I mean, unless you're going to evaluate it. And there are reasons to suspect that it probably shouldn't be used.  

Fidelma: Right, yes. And those, what you've just touched on there as well, you kind of highlighted ethical issues really with screening in this way. So, you mentioned the potential for stigmatising people and I suppose lots of pathologising individuals who may, for example, you know, not feel that their childhood has an impact on them now or may not feel that having experienced particular ACEs, you know, is something that holds them back but learning that they're at an increased risk of all kinds of poor adult outcomes might be really unhelpful and might risk pathologising them. I suppose there is also an argument that if there aren't services available for all the people that are identified as having, you know, higher ACE scores, then that also has problems in terms of the ethics of that?  

Kirsten: Yes, I mean, it's considered unethical to ask people things if you can't help them with them and so I think that you need to have clear services in place to address the issues then when they arise and, you know, in the state of California, they've, kind of, done both of these things. They're using ACE scores to identify children with problems in a way that the article that you mentioned recommends not to do and, actually, a number of other medical bodies have come out and made a statement against. But, on the other hand, when they do find these children, everybody has to fill out their ACE score. They get a score and then they go onto another diagnostics team screener. So, it's a pre-screener in a sense. Now, I'm not sure then how effective it is and it's done anonymously, so nobody is going to be stigmatised directly, they do it on an iPad in an office. But then when they go through the full diagnostic process, they are offered probably some of the best interventions that are available right now in terms of treating symptoms of trauma and preventing things from getting worse. That doesn't mean that they're foolproof but they have invested in some good interventions, so when we wrote our report, we were surprised and raised scepticism about the screening use in the state of California but did praise their use of evidence-based interventions to respond to ACEs. Whereas we've seen practices taking place elsewhere where they're not doing anything after screening for them, they're just asking people and saying, 'Oh well, you're at risk of worse outcomes now, so maybe, you know, need to go seek help and you might want to do it here.' I think that that's the most that we've seen. In some other instances, it's led do activities that aren't tested so we don't know if they're evidence-based yet.  

[Alternatives to ACEs screening] 

Fidelma: So, no one's going to argue that identifying children who need intervention and services and providing with the best of those interventions isn't a great idea. I suppose it's the way in which that's gone about and I suppose that brings us to if screening isn't the right way, what can public health and social care do to prevent and reduce ACE related trauma and to address it? Are there better ways of working with children and families to identify need and adverse childhood experiences that do need intervention and support?  

Kirsten: Well, I can imagine that any child who has been abused or neglected is going to benefit from some kind of help and I don't think you need a score to tell you that. I think that, you know, if they've undergone abuse that they should receive help and that it should be appropriate help and if it's evidence-based, what have they done to identify these things in the absence of an ACE score? You know, there are a variety of diagnostic tools out there that do have the sensitivity and specificity, although maybe not as much as something like the Edinburgh Postnatal Depression Score, but there are things out there. For example, there are a number of trauma inventories but, of course, it wouldn't be necessary to screen everybody in the population for these things. On the other hand too, if we did that and we offered treatment, what would we be preventing? Unfortunately, we don't always have instruments out there that are any better than the practitioner's judgement and the resources that are available to the practice to help families. You know, so what can we do?  

The other thing we can do is we can make sure that preventive interventions are available upstream of treatments. I gave the example before of, you know, having interventions that timed well in children's development that helped them understand the dangers of using drugs, alcohol and tobacco and help them make healthier choices. Help them develop coping skills for dealing with anxiety, etc, and frame what happened to them and, I don't know, help them within their schools, seek support so that they can get better support outside of school if they need it. There are a variety of different pathways that we can do to support children who might be highly vulnerable that one of the things we were worried about is if people are over-relying on these scores, which we know aren't very good, doesn't mean that they aren't doing other things that we know actually are, they're not perfect but they do identify children who need help and they do refer them on to the help that could be beneficial.  

Fidelma: So, these are the universal kind of systems of support and then also selected and targeted interventions and approaches which already have good evidence bases?  

Kirsten: Well, better than no evidence, let's put it that way. Let's be clear, these interventions are not a silver bullet, they're not going to cure all children but you could imagine that if in a well-resourced school, for example, that you have support for the entire classroom to help the children get along better and develop good social and emotional skills with each other and when you notice it, some children might be struggling with that or through these activities you find out that some children need more help, you have the resources within your school to then refer the children on to the appropriately trained individual, probably a psychologist or a social worker who then has the training and the supervision to help the children with the issues that they're experiencing.  

Fidelma: So, we're talking about relationship-based practice and creating that connection with individuals, you know, so if we come away from a focus on screening, how do we identify children, young people who are struggling and might be experiencing adversity, well, through the relationships and contact and those kinds of responses at a relationship level? That's really where the attention and focus, it sounds like, could be better directed to?  

Kirsten: Yes. I mean, like I said, there aren't silver bullets here, okay? But I don't think that the score is going to... it doesn't feel, you know, from the research that we did, that a score is going to substitute any of that judgement. We know already that even any kind of measurer that looks at the risk, for example, of maltreatment, a parent hurting their child is not much better than 50%. It would be nice if we could tell right away, I don't know if that would be nice, but we can't. We can't. We need to rely on well trained and supported professionals to do that and these are very tricky situations, so you're not going to get disclosures or understand what's going on with the individual until you spend some time with them and that requires a skilled therapist who knows how to develop an alliance with the people that they work with and work through some very difficult issues quite often. We didn't find any replacements for that and I don't think you will.  

Fidelma: So, in a nutshell, summing up, there is important learning from the research that has been done around ACEs and understanding those associations between greater adversity in childhood and risk of poor outcomes in adulthood. However, the cautions and limitations you've highlighted are really around, kind of, you know, the narrow focus on the ACE categories shouldn't be something which takes away from also understanding the fuller, wider systemic issues which may also be at play and may, in some instances, even underpin some of the family dynamics going on and cautions around screening. The kind of problems of using ACEs counts at an individual level and we've talked about the risk of stigmatising and pathologising individuals and, I suppose, caution around being deterministic as well. So, yes, is there anything else that you'd like to add there, Kirsten? I've kept you much longer than I intended. That's brilliant.  

[Outro] 

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