Lost In Care

15 years working in residential children's homes. 8 years training foster carers and care staff. Integrative child & adolescent counsellor. 14 years in care as a child. Diary, anecdotes and rants about the good, bad and mediocre. Anonymised but all true.

Trauma, Adverse Childhood Experiences, Determinism and Stigma…

I have been concerned about some of the discussion regarding ACEs and childhood trauma for a while now (while these two topics obviously have a relationship it is important they are not seen as completely interchangeable terms).  I had intermittently been mulling over writing a blog about it.  That said, I do not like it when other people deny reality and prefer to name elephants in rooms so, obviously, this is partly a response to Jessica Eaton’s blog on the same topic, and discussions (I use that word very loosely), which I involved myself in, regarding it on Twitter.

My intention is basically to contribute to the wider debate/thinking and not to personalise it or engage in a war of words.  This post is not intended as a point-by-point rebuttal of either the Eaton post or the Twitter threads.  However, I will be addressing some of the arguments made directly, I do not know how this can be avoided.

Let’s start with the things most of us can probably agree on:

All humans are unique individuals and human beings have a capacity to recover from and overcome the most horrendous experiences.  ACE research is intended to show trends at a population level and not as a predictor of outcomes for specific individuals.  Traumatic experiences can affect different people differently – the reasons for this are not fully understood.  ACE data should not be harvested in a way that has a detrimental impact on anyone, increases their insurance premiums or anything of the kind. Practitioners should not be completing ACE questionnaires as a matter-of-course and without a very clear reason for doing so.  Gathering evidence of the need for intervention is not a substitute for actual intervention, either on an individual or public policy level.  If practitioners are saying things to people such as “you’re going to die 15 years earlier than most people” then this is a complete misunderstanding/misuse of data and, more importantly, is grotesque and insensitive.  When you are working with/supporting another human being, their ACE score should be the furthest thing from your mind.

If you have found yourself nodding in agreement with any of the points above, please try to remember that later when you read something you disagree with – it will be the same person who wrote it.  Disagreement is inevitably heard louder than agreement.

I cannot remember exactly when I first learned about Felitti’s original ACE study, but I remember thinking something along the lines of “this is interesting research and could be useful”.  Useful in the respect that after years of working in children’s homes and being faced with a rather unsophisticated understanding of the young people from many colleagues and other professionals (sometimes very narrow minded and judgmental attitudes), it might help open a few minds.  Useful too in that it might help to reinforce the “invest properly now save money later” arguments with public policy makers and those who hold the purse strings (I am an optimist by nature – although admittedly a very jaded and disappointed one).

I too bristle at labelling and diagnosing.  For example, a personal bugbear of mine at the moment is when I read the words: “…has an attachment disorder”, on referral paperwork at the children’s homes I still sometimes work in.  To which my response is, “diagnosed by who exactly?” Incidentally, if you are a social worker who does this, please please stop.  There are two types of attachment disorder contained within DSM-5, they are pretty rare and would have to be diagnosed by a psychiatrist (I will leave my critique/tirade about most DSM-5 diagnoses for another day).  Terms like secure/ambivalent/avoidant and so on are not disorders, or even diagnoses, they are strategies or, if you prefer, styles.  You may not like these terms either – fair enough, I find them of some limited use but I do not feel passionately about it.  Indeed, when I hear people say: “He is developing a good attachment with…”.  I encourage, when I have the energy, the use of the word “relationship” instead.

However, these frustrations do not mean I dismiss attachment theory as bollocks. It is comprehensive, thoroughly researched and can help shed light and understanding on aspects of the human condition generally and some otherwise inexplicable behaviour patterns specifically. Understanding is what fuels empathetic and relationship-based practice.   The basic premise, that human beings have a need to attach to their primary carers and that what happens in these early relationships affects how we relate to people in the future, holds true.  This means if we are related to in unhealthy or inconsistent ways when we are infants, we are likely to have unhealthy patterns of relating to people as we grow older.  If you consider this “deterministic” then you presumably think there is no benefit to someone of having more positive relational experiences as they grow older.  If you think this, and you work in any helping profession, then I would urge you to reconsider your career choice.

Given that “determinism” appears to be a significant criticism of attempts to understand the impact of early childhood experiences, this is probably a good time to address it:

If two people are in a car accident and they both break their two legs badly, then in the immediate aftermath, neither of them will be able to walk.  Perhaps the doctors will give some kind of estimate on how long it will take for them to recover – this will be based on the average time similar types of breaks have taken to heal.  In reality, of course, one of the people’s legs may well heal faster than the others.  This maybe to do with genetic factors – greater bone density for example, or maybe environmental factors – one has a better diet or is fitter because they workout, or maybe the break isn’t quite as bad.  Perhaps it is a combination of all these things.  We can be certain of one thing though, and this is really important to remember, if neither of them is given the right help/support/treatment then neither of them will walk again.  Deterministic? Yes, I guess it is.  Statement of self-evident truth? Definitely.  Although, I guess, with the right strengths-based approach, they could be taught to walk on their hands.

If you are of the view, as was expressed in a tweet to me, that some people appear to cope comparatively well with years of abuse but for some a one-off traumatic event can have a significant long-term impact, then you are entitled to this view.  But I am entitled to ask: “What do you mean, in this context, by coping?”  This seems like a very important question to me, especially as people can give a very good impression of appearing to cope for many years and then suddenly commit suicide.  I do not expect a precise definition, a five-point checklist or whatever, but just some sense of your thinking around it.

I have already described, in the post immediately prior to this one, how it is your environment which helps build your resilience, or the lack of it, for difficult or traumatic life events.  If you disagree with this explanation then fair enough, but I have a question for you: Why do you think some people are more resilient than others?  Do you believe it is innate in some way?  In someone’s DNA?  You are entitled to that view, but I have another question for you: Remind me, who is being deterministic?

In Eaton’s blog, she states that “51% of the children’s social work workforce were abused in childhood”.  I was genuinely shocked by this number – I had assumed it would be much higher.  But somehow this is taken as evidence of the lack of impact of childhood abuse.  I am struggling to be polite about this, but I am going to try my best.  This argument is complete and utter nonsense. Frankly, if you think that there are not many many people working in children’s social care who are deeply impacted and affected to the point of distress by their own childhood trauma, well, all I can say is: You ain’t paying enough attention.

Let us turn to the neuroscience, where I keep being told the evidence is “scant” and where people identify as “neuro-sceptics” (perhaps this is unfair but it makes me think of climate-change sceptics, in other words “I find the evidence emotionally troubling, or otherwise inconvenient to think about, so I will kid myself that there isn’t any”).  It is true that neuroscience is a relatively new science, but just because we do not know everything, it does not mean we know nothing.  To illustrate this, I will use the case of Shamima Begum:

Nothing, despite the general hideousness of current world events, has made me angrier recently than the treatment of Shamima Begum.  If you believe, as I do, that she was not fully responsible for her actions, because she was groomed and exploited then you cannot also be a neuro-sceptic, or rather you can be, but this would be intellectually incoherent, because the implication is, perhaps gradually and over time, other people, over the internet or in person, changed what she felt, believed and thought to the point where she identified with a death cult.  Where did these thoughts take place?? I am assuming even the most sceptical of you will concede they occurred in her brain – actual electrical activity, new synaptic connections forming and so on.

If you accept that Begum was groomed then, by extension, you accept that experiences and input from the environment altered the activity of her brain in very disturbing ways.  Further, most sensible people agree that she had even less responsibility because of her age.  Why?? It is generally accepted that below a certain age we are not as capable of critical analysis of information we receive, or decision making, and are more vulnerable to negative influences. In other words, our brains are not full developed.

If you can accept this, why would it be difficult to accept that if an infant is exposed to, for example, high levels of fear due to frightening adults, that this could have a long- term impact – not least in their ability to trust other human beings.

To understand what happened to Begum, is not to stigmatise her or victim blame, quite the opposite.  Nor is it deterministic regarding her future, because it means that with different experiences, different input from the environment, she can be de-radicalised.  And the hypothetical infant above can learn to trust.

If you have been involved in, or read, some of the discussions on Twitter regarding ACEs/trauma etc you will be aware that some of them have become extremely divisive/hostile (I accept my share of responsibility for this) and I think it is worth reflecting on why, so I am going to start with a personal example:

My handwriting is terrible, even I cannot read it sometimes.  I have both a narrative and emotional memory of having to go to “remedial class” and being forced to write joined-up which I simply could not fucking do.  At work, colleagues regularly take the piss out of my handwriting, it is a running joke, and each time they do I am filled with shame and embarrassment.  Now, for people who think they can state when someone is coping, I am confident that the world’s greatest body language experts would not notice my distress – they may even think I am enjoying the banter.  My shame and embarrassment are not the fault of my colleagues – I am an adult and could communicate my displeasure. Of course, they are not the cause of my shame anyway – the problem is, in that moment, all the shame I experienced at school is back and I am my 8-year-old self once again.

Now, I do not know I why have bad handwriting, but when I read a Tweet from Beacon House which explained why handwriting ability might be affected by trauma (that is “might be” not “definitely is” nor does it imply that all bad handwriting is a result of trauma) I wondered if that might be true in my case and posted a Tweet to that effect.

Now, a short time later, I read a tweet, under a link to the Eaton blog, in which someone included a photo of their own handwriting and made the point that they experienced trauma as a child and their handwriting is fine – they dismissively refer to the Beacon House tweet as a “trauma fest” (I am not writing this to guilt trip the writer of the Tweet and I have deliberately not named them, if you are reading this then I bare you no ill will and I am sorry for my part in the row, I am simply using it to illustrate my point).  At this point, a few things collide – firstly there is, what you might call my intellectual and moral position, namely that I think it is unhelpful and insensitive to make sarcastic comments about sincere attempts to understand the impact of child abuse, but crucially I am also experiencing a considerable amount of shame.  The shame quickly turns to anger and I respond with mocking sarcasm of my own, and as anyone involved in that particular thread will know, it degenerated from there.  I don’t think anyone could really call it an informed debate.

Perhaps you are someone who thinks you have been relatively unaffected or recovered quickly from your own childhood experiences, perhaps you think you are more resilient than I am and, therefore, your views and opinions on ACEs/trauma/neuroscience etc are more objective than mine.  I am afraid I have bad news for you.  It could just as easily be true that you have been affected much more than you like to think about, understandably, because it is painful, and your arguments against trauma research and determinism are motivated by your desire not to have to think about it.  The evidence pushes at these defenses so you either become angry and lash out or do not consider properly what the other person is saying.  Unfortunately, if we cannot think about the impact our own experiences have had on us, it can be a significant barrier to empathising with other people – because we deny their experience as a way of denying our own.  My point is that, whatever side of the fence we are on, for many people in these discussions it is not just about objective professional opinion but also deeply personal.

Why does any of this matter so much?  Well, because I simply do not accept that much of the ACEs/trauma/neuroscience criticism is about the use of data or an academic critique of research.  Some of it is poorly argued attempts to undermine important truths and understanding.  Sometimes I feel the arguments are the equivalent of a heavy smoker denying the impact on his health by saying: “My gran smoked 60 a day and lived till she was 100…”, while simultaneously coughing his guts up.  I repeat – understanding is the fuel of empathy and relationship-based practice.  Understanding is what can drive progressive public policy and social change, ensuring there is appropriate support for people who have had adverse childhood experiences and services which mean more children are having less difficult lives in the first place.

Put simply, while I still live in a society where the majority of people think the treatment of Shamima Begum is acceptable, while my local secondary school still has an exclusion zone (yes, they actually call it that) and the staff who work in it are told not to interact with the students, while DSM-5 contains meaningless and stigmatising diagnoses such as, Borderline Personality Disorder,  Oppositional Defiance Disorder, Conduct Disorder and many more, while children’s social care remains scandalously underfunded, while children and family centres, youth clubs and other services are still closing, while knife crime continues to increase, while I continue to be met with ignorance, even from experienced professionals, regarding the issues faced by kids in care, I will continue to advocate for a much greater and wider understanding of the impact of childhood deprivations and abuse and I will value any research which helps with this. I wish you all well.

NB. I cannot predict what response this post will get, so I cannot promise in advance to respond to every single tweet or comment, however, I will do my best to engage in debate around it. I imagine if there is any reaction it will come via Twitter – you can say absolutely anything you want to me, literally anything at all. If you communicate with me in a thoughtful way, I will try to reciprocate, but if I perceive your response to be mocking, sarcastic or unpleasant, I reserve the right to respond in kind. If you “like” Tweets which meet those criteria, I also reserve the right to call you on it.  However, I promise you this: I will not mute or block a single individual or thread, nor will I accuse you of being a troll. I have voiced strong opinions which you have every right to challenge and question. Freedom of expression does not mean the right to never be disagreed with.  

 

 

6 Comments

  1. Brilliant!! A well thought out and written response to the weekends events and wider picture of concepts – ACEs, trauma, attachment, resilience, neuroscience.

  2. Suddenly Mummy

    March 21, 2019 at 8:44 pm

    Yes to all of this. The instant dismissal of all neuroscience research as ‘incomplete’ and therefore worthless, is a particular bugbear. The scornful nature of some of the opposition to ACEs is deeply unhelpful to those of us working hard to help professionals to understand the potential impacts of early adverse experiences (and it’s more than trauma and attachment, although that is part of it – ACEs can have measurable effects on physical development, for instance, e.g. neglected babies left endlessly in cots failing to develop sufficient core strength,so we’re not just talking about ‘behaviour’ or mental health) as it gives grist to the mill of those who would prefer to dismiss the whole thing and take the far less challenging route of just believing that some people are, at their core, ‘bad’.

  3. Great stuff. I think what people forget about the ACEs data is that it is in its raw form it is for the medical community. It is the discovery of a risk factor (wish I could underline that) for poor health outcomes. For example Smoking used to be considered harmless. Similar research projects demonstrated smoking is a risk factor in developing lung cancer. Smoking is not lung cancer, it increases the risk of getting it. But still some individual smokers will say things like, “my aunt Mo smoked until she was 99 years old and never had a days illness in her life”. Obviously the medical community is not going to give up smoking cessation intervention based on what happened with aunt Mo. Much of Jessica Eaton’s article was an elaboration in the..” My aunt Mo was fine…” rebuttal to smoking cessation advice.
    ACEs are a risk factor for developing 7+ of the western world’s top causes of mortality. How professionals use the data needs thought, it helps when eloquent people affected by ACEs can discuss it as it provides some depth and context to people wondering weather particular negative or stressful experience is in fact an ACE, (not every harsh word is emotional abuse). Jessica Eaton’s article did touch on something important, the potential for abuse of the data to further disadvantage people. I believe she rightly points out this danger and while one approach to protecting people is to deny the ACE data, I think we have passed that point. Instead there needs to be a call to demand protection under law for people affected by ACEs not to be discriminated against at work, insurance matters etc.

    • Jack Brookes

      March 24, 2019 at 10:43 am

      Yes, that would involve defining what counts as an ACE which would have to involve wider debate than just what researchers have used so far…

      • I would definitely not show up for a debate on what people can call an ACE at the present time. What I hope is we will discover ways to diagnose and treat the health harming changes that have occurred because of toxic levels of exposure regardless of the ACE number. The ACE number is only a screening tool, that is all it was ever intended for. A bit like cervical cancer screening, the smear test is a screen not a diagnostic test, if the result of the screening test is not normal then a referral for a biopsy (diagnostic test). Likewise the ACE screen will be an indication of weather the individual should be referred on to a diagnostic test and treatment if needed. It’s just that we are not there yet, there is no diagnostic test there is no magic bullet treatment. Just prevention. The screening test is still useful in terms of helping people understand where they are at tho.

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