Narrator [00:00:02] Welcome to the Emerging Minds podcast.
Sophie Guy [00:00:08] You’re with Sophie Guy and today I’m speaking with Nicola Palfrey about the research and public health implications of Adverse Childhood Experiences. Nicola is a clinical psychologist and researcher and leads the Emerging Minds National Workforce Centre for Child Mental Health’s approach to trauma, grief and loss, and its impact on child mental health.
[00:00:28] Thank you very much Nicola, for joining us today and coming to have a conversation about Adverse Childhood Experiences.
Nicola Palfrey [00:00:34] Thanks for having me.
Sophie Guy [00:00:35] First of all, I think we probably need to start by asking what are Adverse Childhood Experiences and where did this term come from?
Nicola Palfrey [00:00:42] Sure. So Adverse Childhood Experiences or ACEs came to prominence due to the work of a couple of researchers and clinicians called Felitti and Anda. And the work came about kind of circuitously. One of the fellows was working in a health clinic in the States and actually working it was in the obesity clinic and he found that they had great success rates with their adult clients. However, often when leaving the program, they regained a whole lot of the weight very soon after. And so they did a whole lot of interviews with people, around three-hundred interviews with clients and did a really comprehensive history. And in the case as those interviews were going on, they keep hearing over and over again stories of childhood trauma in particular, tottered sexual abuse. This picked his curiosity. He presented this data at a conference. He was left out of the conference, but an epidemiologist came up to him and said, you can’t present data on three-hundred people, but if you do it on seventeen thousand, for example, then you might get somewhere. So they teamed up and that’s exactly what they did. So over the next period of a couple of years, they did comprehensive sampling of the clients that came to the Kaiser Permanente clinic. So this is a private medical clinic in the states that seventeen and a half of their adult patients, they had their full health history. And they did another comprehensive survey which included these ten questions about adverse childhood experiences and what they were screening for yhere was exposure to what we’re public call potentially traumatic events. So things such as living with a parent with a mental illness, with a parent who’s been incarcerated with family violence, with sexual abuse, physical abuse, emotional abuse, neglect. And then they split them down into a couple of other categories to have ten adult childhood experiences. And then they looked at the correlation between exposure to those adversities and physical and mental health outcomes.
[00:02:42] And really what came out was not surprising, I think, to clinicians, but I think surprising in its scale. So they had a sample of seventeen percent college, a white and college educated people, because they had private medical insurance and they had a really significant proportion of people who had multiple adversities in their life or ACEs. And then there was this really clear stepwise correlation between the number of adversities or ACEs that a person experienced in childhood and their likelihood of poor physical and mental health outcomes. To the extent that at that period of people who had seven or more ACEs in their lifetime had a twenty-year difference in their life expectancy. So there was a seminal study that I think confirmed a lot of what clinicians had seen over the years. A lot of the work that’s been done since then around the pervasive impacts of childhood trauma on brain development, for example, and it sort of came together. And since then, the studies probally been replicated dozens, if not hundreds of times with different samples. So having a look at those really solidifying the data around early exposure to adversity and then risk of poor physical and mental health outcomes as well as engagement in work, poverty in those sorts of things.
Sophie Guy [00:03:57] I’m curious about how did they pick those ten?
Nicola Palfrey [00:04:02] I think they were basing it on what they would consider sometimes what we call the kind of big traumatic events rather than often when we measure adversity this gets a bit confusing with different definitions with sampling and so forth. So I think they were looking at what they had suspected or what from previous research they had thought would have a significant impact on children’s well-being or going into adulthood. And also that some of it was driven, I think, from those qualitative interviews of those interviews with the patients within the clinic. But I’m not I’m not a hundred percent sure, to be honest.
Sophie Guy [00:04:33] Okay. I will now switch to thinking about practitioners and I suppose what this information might bring to them. And curious to know why you think practitioners would want to know, what’s useful for them to know about ACEs?
Nicola Palfrey [00:04:46] I think there’s two different angles to that. The first of which is why is an understanding of the link between exposure to adversity or adverse childhood experiences important if you’re working with children and families. And I think with that the reason that’s important for clinicians is it’s the core to a trauma sensitive approach, really. So we talk about a trauma sensitive approach to either running a school setting or a clinical setting. The fundamentals of that are an understanding of the prevalence of trauma, so how common it is, which is what ACEs is about if you’re screening a population or if you’re an intake, for example, asking a family about their exposure to ACEs. You get some idea of what that family has been exposed to in terms of adversity. And then if you go to ask about that, you need to understand why you’re asking about it. So you want to know the prevalence of adversity and also its impacts or its potential impacts on children and families. And for clinicians to understand that really helps them to work in a way that takes account of the whole child, their experiences of adversity, but also the protective factors. So when we’re asking about adversities, we also want to ask about what might be the buffering effects of that, what would the strong relationships in the child’s life? What was their connection to community and so forth? And I suppose so when we want to know about ACEs, it’s not to replace anything else. It’s because it’s adding into our understanding of of the child and the family in their ecology and everything they’ve been through up until this period. And then the second half of it, I suppose, is to think about when we know about adversities or adverse childhood experiences and their impacts, then that can be really helpful to share with families when we’re trying to work with them to do the best for their children. Helping them to understand the impacts of those exposures and what we can do to mitigate against the outcomes so we can try and change the trajectories earlier on or introduce more of those protective factors because ACEs aren’t destiny. Just because you’ve had exposure doesn’t mean inevitably things are going to go badly for you. But we do know that early. We know what’s going on and understand what’s going on for a child and family and intervene with the right supports, then the more likely we’re going to get a better outcome.
Sophie Guy [00:06:57] And how do you introduce or how would a practitioner introduce and have that conversation around ACEs in a way that is sensitive to how a parent might feel and sort of having that information presented?
Sophie Guy [00:07:11] Absolutely. And I think that’s really important with whenever we question parents, often we get very attuned as clinicians to a whole ream of really personal questions that we ask people. And I think the first step is for us to know exactly why we’re asking those questions. Or earlier point. Why do we need to know? What business is it of ours? And not everybody needs to know. So this particular settings or environments where it may be appropriate for a practitioner to know about the exposure to adverse childhood experience. So say the family GP, it would be really helpful for them to have an understanding of what a family is dealing with so they can offer the right supports and wraparound services. Also in a clinical setting more say in terms of tertiary care. Where your. working with a family in a counselling or myself as a psychologist can be helpful to understand the context of the family so we know what supports to go in. So why are you asking? The question is really important. And then how are you framing it? Are you just asking it to a parent and they think that you’re just writing down a number and judging them against some criteria they don’t understand. It’s not going to get a great result and it’s not respectful of the family that you’re working with, rather giving some information adverce childhood experiences, what we know about them. Their relationship with outcomes in terms of physical and mental health and engagement and why we’re asking about them so we can understand the family and offer support. So I think that contextualising is really important. And when you spend a bit of time to do that, you tend to find that people won’t feel so judged or resistant. But if you don’t do that, they will often find, feel very judged because sometimes that’s what’s going on. And I think when you have that open, shared conversation asking families about what they understand of it, they get it. Because as we know, we all have our own ACEs score. If you talk about how many experiences that we have have grown up in a family that’s divorced and somebody had an alcohol or drug problem or a mental illness, somebody’s been in jail, there’d been some emotional abuse. All of us have scores. We might be a zero. It might be a ten. But all of us have a score and we bring that into everyday life, our interactions and our parenting. So I’ve got a parent with a ACEs score, we’ve got a child with an ACEs score. And we don’t want to say it as that. We want to say that understanding that the numbers can be helpful in a quick shorthand, I suppose, in terms of greater risk with greater number, but they need to be contextualized. So once we contextualise and spend time talking about it in its whole entirety of the child, the family, the person, the community, if you make sure you spend a bit of time with that, that can help reduce that notion of people feeling intruded upon or judged.
Sophie Guy [00:09:56] And that leads me to wondering about are there. Is there a way that this understanding and ACEs and perhaps screening for ACEs can be incorporated into services? And what can you share around how this can be incorporated at a service level?
Nicola Palfrey [00:10:13] So it’s probably safe to say that we’re at the beginnings of that process in Australia around screening for ACEs. I think there’s the utilisation of ACEs or other kind of exposure to adversity. Checklists or those sorts of things in particular services that have been for a lot around for a long time. They tend to be more utilised in tertiary service, such as child and adolescent mental health services where child trauma services where this kind of already established that that’s what is going on for the family.
[00:10:42] But in terms of you to speak in a broader setting, like, like a primary care clinic, for example, or in schools, it’s beginning and it’s being done a little bit. It’s much more established in the US, probably about ten years ahead of us and then increasingly in Scotland and other parts of the UK. And again, in like any screening and I think when we talk to GPs, for example, you know, they have a very particular view of screening and the view of it. And that can be different for different professions in terms of where we see the role of screening and what the purposes of it is. I would say that the strongest evidence is for the use of ACEs screening as in uniform, people that come through the door asked to participate in a asking and answering those ten questions. Have you experienced any of these or has your child experienced any of these ten adversities? Is most substantiated in the evidence in things like GP clinics or pediatrician’s office, for example, where they’re looking at the child top to tail, top to toe [laugh]. In terms of their physical health, but also their gross motor, fine motor, you know, doing that whole child assessment as they move through those developmental stages and working with the family over time. Then you can see it why is a screening of something like ACEs could add to that pool of information. The connection between the clinician and the family. They can understand what’s going on and it’s just one other tool to add to their data around how to best support that family.
[00:12:14] So I think in that environment, it’s well supported in this great examples of that and how and also some evidence around that families find that acceptable. They don’t feel like it’s being intrusive or judgemental because they can see it in the context of lots of other conversations they’re also having about their children and their and their wellbeing and their physical health, rather than just one tick and flick measure of how well their child is doing or not doing. So I think that’s where the evidence is. And I think that’s something that we’re mindful of as we’re looking at trialling this sort of thing in Australia and introducing this to some of the work that we’re doing is it has great value, I think, in some places. But on the other end, if you’re just going to uniformly screen people for something like ACEs or any other thing, anxiety or depression or whatever, we have to be really careful around what we’re doing with that. If we’re going to do that, what do we do with the data? If if it turns out a whole population of young people have a high ACEs score and a certain population, what does that mean? What’s our response to that? So whenever we are asking people questions, I think we have to be mindful of why are we asking it, what we can do with information? How is this actually going to help that person? Because otherwise, it’s data collection for data collection sake. And it’s not necessarily in the best interests of the child or the family.
Sophie Guy [00:13:36] And when you said that it is reasonably well received in the context of a bunch of other questions, were you saying that it’s been fairly successful sort of as a part of a check development sort of tool.
Nicola Palfrey [00:13:47] Yeah, that’s right. So in so in the States, I have a slightly different model around primary care. So they have they don’t have the same level of, say, general practitioners. So that tend to have their family doctor they would refer to as they go to a paediatrician clinic, for example, whereas in Australia we would think of it and forgive me if I get this not exactly correct. Whereas in Australia we kind of think of pediatricians as a very specialist service and you go to the family doctor for those more regular check-ups. So in the States it’s tended to be these peadi pediatric clinics, which we would probably think of as maybe a children’s and family centre or something like that, where you might go in for height and weight, and eyes and ears, and immunisations and those kind of regular check-ups at a family go to. So in that context, yes, that’s where they’ve done most of the research around, you know. So mum might be coming in with child for, say, 3 year check and doing some gross motor skills and fine motor skills. How things going as the ageing has the sleeping and and the pages and pages of screen is that often people are asked to do within that the adverse childhood experiences questions would be asked. And so them and the feedback from that will be given from the clinician incorporating all of that, including the ACEs data and why are you asking about it. And ahm giving, as I said, that context. And often in those clinics, they’re actually also asking the parents if they complete an ACEs score on their experiences in childhood as well as their own children’s experiences, so they can have that conversation around impacts potentially on parenting. And again, that can sound frightening to people, but I think that’s the point at which often parents really get it. They can understand how their experiences as a child, what that was like for them. And I guarantee most people who have had adverse childhood experiences themselves as a child certainly don’t want their own child to go through it. So they can be very open to that conversation about how we know that exposure to A, B and C can increase children’s risk of poor performance at school, greater anxiety, those sorts of things. So it opens up that conversation on that space to say, so what can we do? What can we get in place for your family to ensure your child has the best possible chance to thrive? And the other point about it is, which can be helpful, is the ACEs survey. You get a number, you actually know what the adversity is [uh-huh]. So you don’t necessarily take experience, physical abuse and my father was in prison. You just get two. Yes, so my two is may be different than your two from somebody else’s two. Because the evidence would show we don’t need to know necessarily exactly what the adversity is to offer some support and advice. So sometimes that helps as well, that it’s not quite that. Now, people may go into one to talk about in more detail, but they don’t necessarily have to disclose exactly what the ACE was for us to have a conversation or to start a conversation about how best to support them.
Sophie Guy [00:16:37] This was attempted to be introduced in Australia, wasn’t it? Several years ago, was it?
Nicola Palfrey [00:16:44] I’m not sure there’s been ahm an it tends to differ between state and territory. So we know in Victoria, for example, with the kindy early childhood screen that they do in children entering kindergarten. They do a very comprehensive survey of children’s development said their sleeping, their eating, their exercise, those sorts of things. And they have had questions about their social, emotional wellbeing and their exposure to ACEs just for the last couple of years. And they’ve been testing that acceptability with families and with the schools and so forth. And that’s gone quite well so far. And in the ACT we’ll be introducing that ACEs questions to the ACT kindy check data for which is for all ACT kindergarten starters as of 2019. So there’s there’s still no uniform approach to it. And I suppose that’s one of the things that we’re interested in looking at is whether or not there is interest and appetite for a national even longitudinal survey of adverse childhood experiences. Because there’s a lot of push for that from different sectors. And also I think one of the things that the conversations around ACEs you see in the media a lot and certainly just today they’re talking about it in Wales, it’s being positioned and has been in the states for a while as a public health issue. So people are trying to address exposure to adversity or childhood trauma as a public health issue, because we know there’s such a strong link between poor physical and mental health outcomes the more you have if. And we know what can help to mitigate it. So this is, you know, early intervention, prevention, education and so forth really can help. And so that’s how serious people are taking it. I think one of the great examples somebody gave was when you look at this data, it’s irrefutable. Exposure to adversity is absolutely linked with poor outcomes without intervention. And if that was coming from a water source, there would be an outcry. We would shut that water source down because we know just what the physical and mental cost is, let alone the financial burden and trying to get that message across that if we could appear start talking about these getting programs in place to help families and stop, then down the track we would all be doing much better.
Sophie Guy [00:19:10] I was a little bit curious if you have any thoughts on how because there’s other frameworks out there. For example, there’s the biopsychosocial model, trauma informed practice. How do, this is another sort of layer of thinking about things. How does it fit with those other frameworks?
Nicola Palfrey [00:19:25] Absolutely. So in terms of trauma from practice, ACEs would be one measure that you might utilise in terms of a framework or the ACEs research. The whole body of research would be something that a lot of the trauma and movement would be drawing on. So I always think of trauma informed practice as kind of two halves. One of which is that the knowledge so that understanding, the education, the training of workforce’s or individuals to understand how prevalent trauma is, how it impacts on children and young people, on their learning, on their development and so forth. And what we can do in terms of our interactions with them, whether a school teacher or GP or a social worker to work in a trauma sensitive way, not to make things worse, not to retrigger, not to re-traumatise. And so a lot of the ACEs body of work could inform that and does inform that. And so they fit really, really well together. The other half of trauma informed practice I think of is that kind of lends know that perspective of understanding what I know now about how prevalent trauma is and how it can manifest in different ways with of outward externalizing behaviours or withdrawn behaviours or getting triggered or hyper vigilant or those sorts of things. Having a lens on a child or an adult as it may be around what’s happened to you or for you in your life rather than what’s wrong with you. And I think the ACEs work is, I see it as a kind of pretty solid scientific underpinning or data underpinning behind that. And it’s the trauma sensitive practice wraps around a bit more humanity perhaps in terms of how you what that looks like in a face to face interaction. What was the other one you talked about the link with?
Sophie Guy [00:21:03] The Biopsychosocial model.
Nicola Palfrey [00:21:03] Yeah. Yeah. So I think that it’s a really, really good point. So the ACEs and a criticism of the ACEs I think ahm, which is merited is that it can be seen as a measure or never want to see it as destiny. So you are a six or I’m a two or it doesn’t mean anything in and of itself. Everybody has to be considered in context and the biopsychosocial model is is a fantastic way of representing that. So I might have three adversities in my life and so it may, my sibling, for example. And we may have completely different outcomes depending on what is wrapped around us. So we might be very fami ah similar within our direct family that one of us may have more connections with our grandparents or with school teams or have religious affiliations. So those contextual factors or protective factors as we’ll really need to be taken into account. And actually a lot of organizations, when they are utilizing something like an ACEs framework to screen for adversities, are also screening for predictive factors as well to try and give them much to make sure that the balance conversation is there. I supposed that’s one of the things that we would always talk about. If you’re if you’re ever going to even be talking about ACEs or adverse experiences with a family or with a child or young person, you always want to wrap that around a conversation of what is going well in your life for you, what’s protective, what makes you feel good because you’ve got to have a balance. And we need to understand the yin and the yang of an individual and a family and a community so that biopsychosocial model is always going to have in the back of your mind that there’s no one measure that will tell you how a child is travelling or certainly not how how things are going to travel in the future for them.
Sophie Guy [00:22:46] Yeah, that makes a lot of sense. I feel as though we’ve covered everything that I was going to ask you.
Nicola Palfrey [00:22:53] I went bit around the world.
Sophie Guy [00:22:53] That was really good so thank you very much.
Nicola Palfrey [00:22:55] Pleasure. Thank you for doing it.
Sophie Guy [00:22:57] My pleasure.
Narrator [00:22:59] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.