ACEs – repackaging old problems in shiny new (Emperor’s) clothes: Professor Morag Treanor
Morag Treanor is Professor of Child and Family Inequalities, and is based at the Institute for Social Policy, Housing, Equalities Research at Heriot Watt University. Morag’s research uses longitudinal methods, both quantitative and qualitative, to explore the impacts of poverty and persistently low income on children’s cognitive, social, emotional and behavioural developmental outcomes and educational transitions. Her published work is concerned with the impact of family, peer and social relations on child wellbeing for children living in low income families. In this blog she provides a critique of the ACEs framework, raising questions not only about how we understand poverty, but how these understandings should inform policy .
Adverse Childhood Experiences (ACEs) are defined as stressful events that occur in childhood which are believed to have lifelong impacts on health, wellbeing and health-related behaviours. This blog highlights some (but not all!) limitations with ACEs as a concept and a practice.
ACEs is a particularly deterministic concept: the effects of having ACEs is though not only to lead to a degraded life and early death, but also to defective parenting, which, it is asserted, will lead indisputably to ACEs in the next generation. The original study defines ten ACEs as: domestic violence; parental separation/divorce; having a parent with a mental health condition; being the victim of abuse (physical, sexual and/or emotional), being the victim of neglect (physical or emotional); having a member of the household in prison; and/or growing up in a household in which there are adults experiencing alcohol and drugs misuse (Felitti et al., 1998). Note that all of these ten ACEs are situated in the home, more of which later.
The ACEs study also lacks nuance. Each of the ten adversities are summed to give a total ACEs score, with no distinction between types of ACEs, which include everyday occurrences such as parental separation and, rarer, criminal acts such as sexual abuse. Each ACE is weighted equally in the final score. This ‘risks blurring the boundaries between normal and abnormal experiences, pathologising a very large proportion of the population and undermining the possibility of meeting the specific needs of people with serious problems’ (Macvarish and Lee, 2019: 469). Let’s look at the circumstances that are not ACEs: loss of benefits; benefit sanctions; exhausted parents working multiple shifts; children looking after siblings and taking on domestic responsibilities to facilitate low quality parental work; young carers; families with a disability; children without a family; children looked after by the state; rent arrears and homelessness; racism; peer-bullying; group-based bullying and discrimination, eg LGBT; unsafe neighbourhoods; low quality housing and damp, cramped homes; a lack of food on the table; services whose funding has been cut to the bone or have disappeared; children who are sexually exploited; bereaved children; socially-isolated children; refugee and asylum-seeking children; and children who are far from home due to political violence, war and instability. I’m sure you could add to this list of non-ACEs. What you will note is that many of these non-ACEs are only within the gift of governments to solve.
The original study also suffers from not being a population-based study, rather it comprises a sample of predominantly white, middle-class, adult, private health insurance (Kaiser Permanente) patients (Felitti et al., 1998, McEwen and Gregerson, 2019). This makes it a very biased sample, one that, for example, excludes the study of socioeconomic disadvantage (privately insured) and ethnicity (predominantly white). Another limitation is that ACEs are based on a deficit model of the family, of parents, and of mothers especially: they are centred on the quality of parental caregiving, particularly mothers’, making the family the cause of, and the solution to, adversities experienced (Macvarish and Lee, 2019). The ACEs concept does not include assets, or protective factors, or family and community support, or other resources (McEwen and Gregerson, 2019). Add to this the fact that parenting and family is culturally specific. Hartas (2019) finds that there is a very low prevalence of ACEs reported in Asian families compared to white, Hispanic and other groups, suggesting that there are cultural and ethnic influences on perceptions of parenting and childhood experiences. As with other family-deficit models that seek to explain inequalities in childhood, the parenting of those from a lower social class and/or non-white ethnicity, particularly mothers, is being held up against upper-middle class white standards and found lacking.
Let’s now turn our attention to the children. ACEs looks at the adverse circumstances and experiences of children as a result of their families rather than as living within families experiencing the same circumstances. The extensive research on poverty shows that parents sacrifice much to provide for their children, including food (Treanor, 2014). Furthermore, when there is only one parent to make those sacrifices then lone parents are easily as, or more, deprived than their children (Treanor, 2016). ACEs give no consideration to the families in which children live: yet you cannot improve the circumstances of children without improving those of their families. Another limitation in relation to children arises because ACE advocates advance that the first three years of a child’s life is critical to the rest of its life and that untold damage can be done in this period. A problem with this is that such ideas would deem older children to be irreversibly damaged. This takes away attention, funding and potential interventions for one of the most important stages of childhood, one with immense periods of growth, development and malleability, at a time when they can exercise agency and take ownership of interventions: i.e. adolescence. The ACEs approach thus writes children off at this critical stage of transition and adolescents get overlooked.
ACEs also ignore the structural circumstances in which children and their families live. Children are more likely to experience adversity in childhood when they also experience poverty and inequality. Poverty has hugely detrimental effects on all aspects of a child’s life, including: education, family life, mental and physical health, and future (un)employment. This means that poverty and inequality have detrimental effects on the areas of life that are being attributed to ACEs, usually without any analysis of poverty or inequality per se (Steptoe et al., 2019). In a systematic review of ACEs and the socioeconomic position of the family, Walsh et al (under review), screened 2825 papers on ACEs but only 6 included family socioeconomic position. They widened their screening to include ‘child maltreatment’ and of 4562 papers, only 35 (including the aforementioned 6) mentioned family socioeconomic position as a potential explanatory variable (Walsh et al., under review). Of those that did, almost all showed a clear association between childhood socioeconomic position and risk of ACEs (Walsh et al., under review). In one study, the authors find that ACEs are over 10 times more likely to occur in the poorest 20% of the population compared to the richest 20% (Marryat and Frank, 2019, see also our blog by Dr Marryat).
Despite the strong evidence on the effects of poverty on children’s lives, ACE advocates posit that poverty is caused by the presence of adversity in childhood and not the other way around. A recent study of ACEs in Wales, argues that ‘those with 4+ ACEs were more likely to live in deprived areas, be unemployed/on long-term sickness and have no qualifications’ (Bellis et al., 2013: 89). Here, association is being mistaken for causation and cause and consequence are being conflated. By assuming that ACEs lead to poverty, rather than be a consequence or manifestation of it, policy focuses firmly on ‘family intervention to support parents to ‘nurture’ their children as a means of countering the toxic effects of rising inequality’ (Hartas, 2019: 6). That is, parents are being encouraged to nurture their children better to alleviate the negative impacts of systemic inequalities, such as poverty, rather than society tacking the systemic inequalities in the first place (Hartas, 2019). This risks promoting policies that do not increase and, in fact, may decrease income to families facing poverty and inequality, such as we have seen in this past decade of austerity.
The final problem with ACEs is that, instead of shedding light on an emerging social problem, old problems are repackaged and the thinking becomes ossified. The idea of ACEs is simple, simplistic and intuitive, which is why it has caught the political and public imagination. It offers a simple solution to complex problems. However, it very much lacks scrutiny through a critical lens and has been adopted without question. Furthermore, it blames those it purports to help. This is problematic.
References
BELLIS, M. A., LOWEY, H., LECKENBY, N., HUGHES, K. & HARRISON, D. 2013. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health, 36, 81-91.
FELITTI, V. J., ANDA, R. F., NORDENBERG, D., WILLIAMSON, D. F., SPITZ, A. M., EDWARDS, V., KOSS, M. P. & MARKS, J. S. 1998. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults:The Adverse Childhood Experiences (ACE) Study. AMEPRE</cja:jid> American Journal of Preventive Medicine, 14, 245-258.
HARTAS, D. 2019. Assessing the Foundational Studies on Adverse Childhood Experiences. Social Policy and Society, 1-9.
MACVARISH, J. & LEE, E. 2019. Constructions of Parents in Adverse Childhood Experiences Discourse. Social Policy and Society, 18, 467-477.
MARRYAT, L. & FRANK, J. 2019. Factors associated with adverse childhood experiences in Scottish children: a prospective cohort study. BMJ Paediatrics Open, 3.
MCEWEN, C. A. & GREGERSON, S. F. 2019. A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years. American Journal of Preventive Medicine, 56, 790-794.
STEPTOE, A., MARTEAU, T., FONAGY, P. & ABEL, K. 2019. ACEs: Evidence, Gaps, Evaluation and Future Priorities. Social Policy and Society, 18, 415-424.
TREANOR, M. 2016. The Effects of Financial Vulnerability and Mothers Emotional Distress on Child Social, Emotional and Behavioural Well-Being: A Structural Equation Model. Sociology, 50, 673-694.
TREANOR, M. C. 2014. Deprived or not deprived? Comparing the measured extent of material deprivation using the UK government’s and the Poverty and Social Exclusion surveys’ method of calculating material deprivation. Quality & Quantity, 48, 1337-1346.
WALSH, D., MCCARTNEY, G., SMITH, M. & ARMOUR, G. under review. The relationship between childhood socio-economic position and Adverse Childhood Experiences (ACEs): a systematic review.
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Whilst an appropriate methodological critque, what I hear most loudly from your blog is a research agenda to provide the nuance external validity and reliability of the concept. What happens in childhood shapes us, we all ‘know’ that and countless academic studies support that. A great benefits that acceptance of the ACE’s frame provides for me, is that it attacks directly the dangersous right wing dogma that individual choices are the key determinant of success. A dogma repeated by those , often with their hand on the policy tiller, whose lives were handed on to them on a plate and to whom doors open wide. Importantly though they are well rested enough, well fed enough and confident enough to walk through them. I see this blog as the first page of a Horizon 2020 grant application on bringing resiliance to ACE’s.
Context IS everything (to borrow from your colleague’s blog https://blogs.ed.ac.uk/CRFRresilience/2019/07/08/context-is-everything/). Given your final paragraph, the analogy of a zoom lens comes to mind. We can zoom into the contexts of details; the child, the family, and within that scope, recognise that adverse childhood experiences *may* lead to poor outcomes for some. There is a correlation, for sure.
However, when we begin to zoom out, other contexts come into play. Resilience (individual, family and community), social justice, poverty and structural violence are implicated. Zoom out further, we might think of capitalism, patriarchal structures and consumerism as being determinants, too. ACEs simply zoom in to specific details, ignoring the wider contexts. The danger of ACE’s being used as a predictive tool (especially by insurance companies ) is deeply concerning and becoming a reality. That ACEs might be seen as causative of poverty is equally troubling and, simply repackages victim-blaming.