Making Scotland an ACE informed nation

Making Scotland an ACE informed nation

Continuing the conversation at the Centre for Research on Families and Relationships

Context is everything…? – Dr Louise Marryat

Dr Loiuse Marryat is a Research Fellow in Pediatric Neurodevelopmental Disorders and Learning Difficulties at the Centre for Clinical Brain Sciences, University of Edinburgh. Louise is a quantitative researcher with a background in sociology, public health and statistics. Her research has primarily focussed on the use of longitudinal and routine datasets to explore a diverse set of topics around child and maternal health. She is particularly interested in early child development, particularly in relation to neurodevelopmental disorders and mental health.

Louise’s recent articles include ‘How community resources mitigate the association between household poverty and the incidence of adverse childhood experiences‘ (with Alexandra Blair and John Frank) and ‘Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study‘ (with John Frank). 

Epidemiology tells us about the patterns of disease in the population, as well as their causes, and – potentially – their prevention. The premise behind it is that disease is not random but occurs in patterns that reflect their causes. By identifying the patterns, we can start to think about what the causes and preventive actions may be. This sounds relatively straightforward; however humans are complex beings, with many different factors influencing their pathway through life, and thus the health outcomes they experience at various ages. Many of us who study this field look to the socio-ecological model when examining the many causes of outcomes. The socio-ecological model points to different levels of influence on an individual’s lifelong outcomes, from genes and child characteristics, to home environment and relationships with parents, to schooling, and the wider social and political culture in which we exist.

The Adverse Childhood Experiences model is primarily an epidemiological tool. That is, it was designed to explore patterns of adult disease in the population in relation to early adversity. There exist many good critiques of the ACEs model ( for example, https://socialpolicyblog.com/2019/06/11/adverse-childhood-experiences-are-not-the-answer-for-policy/ ; http://publichealthy.co.uk/good-intentions-but-the-right-approach-the-case-of-aces/ , along with the others in this series), and I don’t plan to reinvent the wheel. However, whilst the model clearly has its flaws, as an epidemiological tool, which demonstrates increased risk of certain adverse outcomes as the number of ACEs experienced increases, it is of interest. What it is not, is a validated scoring card for predicting individual outcomes, and I know that I am not alone in my concern about its increasing use as a screening tool in a variety of settings. It is also of less use without considering the context in which a person is living i.e. the wider socio-ecological model. Despite the often cited rhetoric that ACEs occur across the population, data from our recent paper suggested that, although some children in all sectors of society experience ACEs, children living in low income households in Scotland are far more likely to experience ACEs, and experience a higher number of ACEs than children living in the most affluent households (Marryat and Frank, 2019). 

These families may also have fewer resources both within and outwith the household to compensate for these experiences: recent evidence suggests that access to good public transportation in Scotland may reduce the inequalities in the distribution of ACEs, although we can only hypothesise why that may be (Blair et al., 2019). In particular, the ACEs tool, as commonly used, lacks any measures of positive childhood experiences, such as the presence of a loving and supportive adult in the child’s immediate circle, whether or not that person is the child’s parent.  There is a well established body of research demonstrating that such positive experiences can buffer the effects of ACEs to a remarkable degree (Werner, 1980.) The classic ACE tool is thus an unbalanced assessment of early life influences that can impact on later life.

The discussion around ACEs often reminds me of one of my first stats lectures, where we were told that on days when more ice creams are sold in Australia, there are more shark attacks… We could easily conclude from this that sharks love the taste of ice cream, but the more realistic hypothesis is that more people are on the beaches and in the water on hot days (when more ice cream is sold), thus increasing the likelihood of a shark attack. ACEs are currently being cited as a key cause of later outcomes and we are frequently told by the ACEs movement that we don’t need more research on this. I would argue, however, that our understanding is just at the tip of the iceberg. Understanding where ACEs sit within the rest of the socio-ecological model, whether that be in the context of genetics, relationships, or structural influences such as poverty, is key to developing our knowledge about the associations between ACEs and later outcomes, as well as to discovering more about how best to support families to create the best childhood possible for their children.

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