The multi-heads of the ACE hydra
BACP Children, Young People and Families Journal, March 2019
Rachel Eastop concludes her mini series with a look at the increasing prevalence of adverse childhood experiences
Childhood adversity literally gets under our skin, changing our brains and bodies.
Dr Nadine Burke Harris – The Deepest Well1
Without exception, the number one reason for referral to either the children and young people’s counselling service I’ve managed over the last 12 years and to my own private practice, is anxiety. Stress and anxiety are at an all-time high and, following a conversation I had with teachers at a local school in Edinburgh this week, there is seemingly no single cause of, or answer to, this ‘epidemic’ in childhood mental health.
But thankfully, in recent years, our understanding of how levels of stress can impact the brain and body has increased.
Of course, positive stress is normal and an important part of growing up. It tends to be mild and brief, causing slight increases in heart rate and changes in hormone level that return to normal fairly quickly. Tolerable stress tends to be more severe and has the potential to affect a child’s development. Its effects, although negative, are moderated by its limited duration, which allows the child’s brain to recover over time. But then there’s toxic stress, which is the extreme, frequent or extended activation of the body’s stress response without the buffering presence of a supportive adult.2 This can then lead to serious implications for a child’s developing brain and body.
The term ‘adverse childhood experiences’ was originally developed as part of a research study carried out by Vincent Felitti and Robert Anda, between 1995 and 1997, in which 17,000 adults were surveyed.3 This ACE study focused on three areas during childhood:
Abuse – physical, emotional and sexual
Neglect – physical and emotional
Household dysfunction – mental illness, mother treated violently, substance abuse, divorce and incarceration.
In addition to this original survey, seven more ACEs have been added to the list:
Living in care
Death of a parent/guardian
Separation/deportation from primary care giver
Witnessed/heard community violence
Discrimination of any kind.
In recent years, ACEs have become a hot topic, so much so that in September 2018 Scotland pledged to become the first ACE-Aware Nation. I was at the ACE-Aware Conference in Glasgow, and although I was ‘fired up’ to be part of this powerful movement, I was left wondering how this would translate in real terms and how ACEs would affect my work with children and families going forward. I mean, have I and many others not been working with ACEs for years? What’s new?
Being exposed to ACEs not only affects brain development, but can change children’s hormonal systems, immune systems and even their DNA; and along with this, behavioural issues, learning difficulties and health problems. What’s new is the link between prolonged, excessive toxic stress and physical health, and in turn, life expectancy. Medical professionals are beginning to sit up and take notice because it seems, for the first time, that mental health and physical health have a direct link. This is a game changer for the medical world as they can re-evaluate and redirect treatment because there is now ‘cause and effect’. And if childhood adversity can be reduced, there will be less addiction, obesity and early death, which will save lives and save money.
And for us?
But as therapists we’re not so interested in medical outcomes, rather therapeutic ones. There was a time when I saw my counselling practice in schools as a support and addition to the other services available as part of a multidisciplinary team. But annual cuts to service budgets have left us experiencing intolerable stress.
We all know that childhood trauma will not stop overnight, and it will perhaps take a generation to educate and make the changes necessary in the lives of individuals and decision makers. Early screening, combined treatment strategies and universal support is the gold standard, but as we know, reality often looks different, and an already stretched health service and education system have left the usually supportive adults needing counselling themselves.
In my last article, I mentioned that the First Minister of Scotland had announced that funding would be given to provide school counsellors in 350 high schools. A report, Children and Young People’s Mental Health Task Force: preliminary view and recommendations from the chair,4 was published in September 2018, and following this, plans have been put in place to employ school counsellors. The counselling world has been assured that these counsellors will be qualified, have received additional training to work with children and young people, be accredited with either BACP or COSCA and will receive clinical supervision. This is excellent news, but it’s unclear at this stage exactly what this will look like, and it is unlikely anything will be in place before 2020.
So how can counselling play its part when there is, as yet, no formal approach in place? Perhaps the answer lies with our involvement with parents. When I first started working as a school counsellor, I welcomed the opportunity to ‘bypass’ non-compliant and disengaged parents, providing children and young people with point-of-need, easily accessible counselling, which didn’t rely on parents to pay, provide transport or even attend meetings. I enjoyed letting the school guidance staff connect with parents, and I could remain in my counselling room, hidden behind my ‘client confidentiality’ banner. Client confidentiality is vital, of course, but it gave me an excuse to ignore parents. My views changed when I set up a private practice and developed a good professional connection with parents – while still holding appropriate client confidentiality, of course.
Parents and the wider family do play a vital role in the counselling process. Never in the room, yet always in the room, parents have the biggest influence – both positive and negative – on a child’s ability to cope with their lives on a day-to-day basis. And one of a child’s greatest buffers is also the teacher and the other adults who surround them. B
ut parents are stressed, teachers are stressed and services are stretched, so it’s no wonder children are anxious in droves these days. I’m becoming more and more concerned about the amount of experienced and robust teachers now off work with stress and dreading returning, not just because the job is demanding, and many pupils have constant unregulated fight/flight/ freeze survival systems, but because their role is, in turn, not buffered by supportive leadership. This consequently activates their own stress response and the school environment can become chaotic and unsafe for everyone.
A school counsellor cannot be all things to everyone, but there could be an opportunity here for those of us in the field and those hoping to be, to make a difference to childhood and the prevalence of ACEs. If a formal job description of ‘Children and Young People’s Counsellor’ could be written and a pay grade fixed, counsellors would be able to provide a consistent, buffering presence in schools for both staff and pupils.
If, in addition, no time limit (such as six–eight sessions) were enforced on the work, a counsellor would be able to address the developmental trauma and anxiety experienced by so many children. Emotional and attachment issues could also be addressed and, in partnership with other vital services, we could begin to repair the increasing traumas experienced by our young people, using the ‘bottom-up’ approach.
1 Burke Harris N. The deepest well: healing the long-term effects of childhood adversity. Basingstoke: Pan Macmillan Bluebird; 2018.
2 https://centerforyouthwellness.org/ ace-toxic-stress/
3 Felitti VJ, Anda RF, Nordenberg D et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventitive Medicine 1998; 14(4): 245–58.