Adverse Childhood Experiences and education — a newbie teacher’s perspective

Many of you will have already seen ‘Resilience’, a brilliant film about the “biology of stress and the science of hope”. It’s been shown at numerous events over the past few years and is being shown on TV in the UK for the first time tonight.

It’s a very powerful film, which explains the science and practical impact of Adverse Childhood Experiences (ACEs). In no small way it has contributed to much of the growing understanding of ACEs, and the recent push for Scotland to become a ‘ACE aware nation’.

I started writing this blog at the start of the lockdown since it seemed like a good time to catch up on some professional reading, and, well, I wasn’t really going anywhere.

Brief disclaimer before I start. This is a slightly more ‘academic’ blog than my usual style, but I should say from the outset I am not an academic. I’m a newly qualified teacher who had a career change last year after working for many years in children’s policy and researching looking at looked after children, attainment, adolescent mental health, trauma, bereavement, attachment, loss and transitions.

In recent years there has been much discussion about Adverse Childhood Experiences (ACEs) and the impact they have on young people right now and in the future. A focus in Scotland has been the impact of ACEs on the ‘attainment gap’ and how this can be tackled.

The Scottish Government has also made ACEs a political priority, including it in their Programme for Government. The broader context in Scotland can be found in the government-wide policy of ‘Getting It Right For Every Child’ which more recently has included a commitment to “prevent and mitigate adverse childhood experiences for children and young people”.

Throughout my previous career, during the PGDE, student placements and in CPD now ACEs features heavily and is explained as a vital piece of the jigsaw in understanding young people and how they learn. Educational social media is awash with the subject. And as I’ve already mentioned, the well-known and very watchable film “Resilience” is a staple in many CPD sessions. Advice for interview prep for teacher’s jobs includes the “make sure you talk about ACEs — they’ll love that” line.

On one hand it’s a real positive that people have got to grips with changing understanding of how young people experience trauma. On the other hand it’s fair to say there has also been some challenge to the way the ACEs research has been used in practice.

Discussions about pupil attainment have sometimes been couched in language about “high levels of ACEs” without any real context. (I should say I’m fortunate in my current teaching post that at a very early CPD on managing challenging behaviour the excellent teacher leading the session cautioned against an overly simplistic understanding of ACEs and encouraged us to read some of the wider literature on it).

So, with all that in mind, I wanted to dig deeper into the research on ACEs to work out if Scotland becoming the first “ACE aware nation” was likely to have the impact many hope it would on educational outcomes.

It turns out the the start of lockdown was an excellent place to start.

No sooner had I refreshed my mind on a series of reports I had written over the the past five years than a new piece of research was published by one of the very researchers who had authored the original ACEs study.

Robert Anda et al make a series of cautionary statements in this latest research (published March 2020) on the ACEs model, including outright criticism of its use as a screening tool for individual young people to stating “the ACE score is neither a diagnostic tool nor is it predictive at the individual level”. This is a crucial statement, worth repeating again:

“nor is it predictive at the individual level”.

Most people who are directly involved in the research on ACEs already know this of course. But that message filters down in different ways, and in both educational and policy making circles in Scotland I’ve frequently come across those who do advocate individual ACE screening as part of a package of services that can be provided for that individual. I’ve even sat through a training course where we were asked to share our own ACEs score as an icebreaker before we could truly understand young people.

Childhood trauma

Unsurprisingly research on childhood trauma and ACEs has many areas of shared learning. Margaret Blaustein (2013) notes:

“children who have experienced trauma may struggle with a multitude of competencies that influence school performance and engagement, including concentration and attention, managing behaviour, negotiating relationships, regulating emotions, executive functions and goal-oriented actions, a belief in the capacity to build a future and faith in having the potential to work toward one”

I’m going to use Blaustein’s impacts as a bit of a thread through this blog as they are crucial factors in understanding engagement and attainment in the classroom.

What are Adverse Childhood Experiences (ACEs)?

Felitti et al in their 1998 study “relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study” set out to demonstrate a link between risk taking health behaviours and poor health outcomes and experiences in the early years related to trauma, abuse and other problematic behaviours in the household.

They concluded not only that these adverse experiences were far more commonplace than previously understood, but that there was a much clearer link between the prevalence of them and the increased risk of poor outcomes in later life.

Later research built on the conclusion that it is the cumulative number of ACEs that leads to poorer outcomes, rather than individual ACEs — and that the risk of poor health outcomes increases as the prevalence of ACEs increases (Mersky et al. 2017). Hunt et al. (2017) and Hertel and Johnson (2013) build on this finding, with both studies concluding the severity of the individual experience has less impact than the total number of ACEs.

The prevalence of ACEs differs from study to study, in part because of the self-reporting nature of the underlying research. The US National Survey of Children’s Health (NSCH) found that 48% of children had experienced one ACE, with 22.6% experiencing two or more (Blodgett and Lanigan 2018). The 2016 ACEs study in Wales found that 46.5% of those who participated had experienced one ACE with 26.6% having experienced two or more (Bellis et al. 2016).

The 1998 ACEs Study was epidemiological by design, and thus focused on health outcomes. The prevalence of disease and other health risk factors (such as alcoholism, sexually harmful behaviour or obesity) were the key conclusions from the research (Felitti et al. 1998).

Given the respondents had a mean age of 56 years, the study was not designed to identify potential risks or challenges for children as a result of adversity in early years. This, as Hunt et al (2017) argue, means the “proximal effects of ACEs” (p392) have had very little focus. Burke et al. (2011) further recognise this and conclude there is “a gap in the literature in terms of examining ACE categories in paediatric samples” (p2). Blodgett and Lanigan’s 2018 study noted the lack of focus on academic outcomes and the link to ACEs, in particular on attendance and reasons why students failed to meet expected standards.

Despite this recognised gap in the literature, there are a some studies which have looked at the effects of ACEs on children’s learning. These have focussed on resilience (Bethell et al 2014); cognitive development (Johnson and Blum 2012); behaviour (Sciaraffa et al. 2017) and school attendance (Stempel et al. 2017).

In addition, the Burke et al (2011) study finds more generalised links between ACEs and poor learning outcomes, concluding that four or more ACEs resulted in behavioural problems in 51% of cases, compared to 3% of cases for those with no ACEs. As a result, despite there being more limited research in this area than in health research for example, there is very clear evidence of the impact of childhood adversity on learning.

Resilience and school engagement

A study of resilience within the context of ACEs found that children who have experienced one or more ACE were less likely to demonstrate resilience than those who have not experienced any (Bethell et al. 2014).

However the study also found that almost half of children who demonstrated resilience had experienced at least one ACE and a similar number who “usually or always engaged in school” had experienced one ACE (ibid.).

The research suggests that it is the response to the adverse experience and the promotion of resilience in the family, community and at school which mitigates against the long-term impact (ibid.). Eeverly and Firestone (2013) develop this further identifying the ability to “rebound” as the key factor in resilience — how able are children to cope with and move on from traumatic experiences and what support can schools put in place to assist in that process (2013 p290).

This concept of resilience within the study of ACEs was also researched by Sciaraffa et al (2018) which concluded that protective factors put in place by educational professionals could improve resilience and “buffer some negative impacts” of ACEs (p352). While these approaches would not be able to completely mitigate the impact of the childhood trauma, the research finds it could have a positive impact on the key elements of child resilience — “self-regulation, social competency and self-efficacy” (ibid.).

Cognitive and personal development

The impact of ACEs is not restricted to poor physical health alone, but to cognitive development as well as physiological and emotional impacts (McDowell 2017).

The ‘biology of stress’ as researched by Shonkoff and Garner (2012) details the potential impact of early stress on brain development and introduces the concept of ‘toxic stress’ — that is the most severe stress which is regularly experienced without any protective relationships to provide the sense of safety and security which might calm the body’s stress systems.

Further research has pointed to the impact of toxic stress on cognitive and emotional development and found that it has long-term implications not just in early years but into adolescence and adulthood (Johnson and Blum 2012).

Carrion and Wong describe this trauma as “a threat to an individual’s wellbeing” (p23) with all the effects that brings to physiological and neurological development, including poor memory recall and lack of or reduced self-control (Carrion and Wong in Johnson and Blum 2012).

This is echoed in Shonkoff and Garner’s research which notes that higher rates of toxic stress can lead to “less outwardly visible yet permanent changes in brain structure and function” among children (p236). This leads to long-term difficulties in brain development with the resultant problems in health, learning and social and emotional behaviour, and directly impacts on education through poorer school performance and increased absenteeism.

Hertel and Johnson (2013) explore this further in researching the link between early childhood trauma and the basic skills necessary to engage in learning — such as rationalising thoughts, focussing on tasks and being able to concentrate in lessons. They quote Dr Kenneth Fox, a high school teacher summarising attempts for children to focus on learning while experiencing trauma as “like trying to play chess in a hurricane” (p27). Whilst this is an anecdotal analysis from an educationalist, it is a good summary of the literature on the complexity of children’s lives because of traumatic experiences.

Sciaraffa et al. (2018) looked in detail at this theory by breaking down what poorer school performance looked like in practice. They formulated five broad categories — attention deficit; language deficit; problem solving difficulties; difficulty acquiring new skills or information and problems with consequential reasoning. These are expanded to look at broader elements of personal and social development around self-regulation and interpersonal skills. Self-regulation is identified by Sciaraffa et al. as a particularly important stage in childhood development and crucial to ensuring children engage positively with education. For children with multiple ACEs, the research suggests additional support will be required for them to “identify, express and cope with conflicting emotions” (ibid. p346) and that without this support their learning will suffer, or they will disengage from classroom activities.

Hertel and Johnson also study this from the perspective of social-emotional functioning, and similarly conclude childhood trauma has a significant impact on the child’s ability to form and maintain relationships and be able to regulate emotions (2013). They conclude that these basic social functions are the key building blocks to being able to learn and that the absence of these ‘soft skills’ “frequently interferes with academic functioning” (ibid. p30).

McDowell (2017) points to these aspects of children’s developments as an area requiring further study, especially the interplay with the school environment and what impact teachers and other professionals can have on these issues. This is echoed in the research of Blaustein (2013) and Hertel and Johnson (2013) who identify aspects of teaching which can alleviate some of the impact of poor social development as a result of early childhood trauma.

Behaviour

The most frequently demonstrated impact in the literature of ACEs on learning is around behaviour. Multiple studies have shown that the higher the number of ACEs the greater the chance of involvement in negative behaviours and the greater risk of having a diagnosed behavioural condition (Burke et al. 2011; Freeman 2014; Hunt et al 2016). As with the greater risk of disease and adverse health experiences in later life, the detailed paediatric study of Burke et al. found that there was a significantly higher risk of behavioural problems in children who had experienced four or more ACEs.

Freeman (2014) and Hunt et al. (2016) break the behavioural data down into two categories — internalised (that is behaviour which is not visible, for example anxiety) and externalised (that is behaviour which is visible, for example violence). Freeman concluded that three or more ACEs increased fourfold the risk of internalised behaviour and four or more ACEs carried a five times greater risk (2014). A pattern was also clear with escalating (negative) behaviour related to the greater number of ACEs. Similar data can be found in other studies such as Blodgett (2012) which found children with at least three ACEs were six times more likely to display problematic behaviour. Hunt et al. and Freeman’s notion of ‘internalised’ behaviour is often misunderstood in the classroom, with the children labelled as “disengaged, disinterested and unwilling to cooperate” (Hertel and Johnson 2013 p28).

One of the criticisms of the original ACEs research was that it did not have a focus on poverty, however the study by Hunt et al. (2016) found that even considering differentials in family income the link between ACEs and behaviour remained. The conclusion was that it was the adverse experience that was the key determinant of behaviour rather than the socio-economic status of the family.

Hunt et al. (2016) and Sciaraffa et al. (2017) go further to look at the link between ACEs and the diagnosis of behavioural conditions, namely Attention Deficit Hyperactivity Disorder (ADHD). Hunt et al. found that the odds of being diagnosed with ADHD increased with each additional ACE (regardless of what the specific ACE was). Similarly, Brown et al. found that children with an ADHD diagnosis had a much greater exposure to ACEs, and that the severity of ADHD was also linked to the number of ACEs (2017).

However this could be challenged by the findings from Shonkoff et al. (2012) which suggests behaviour related to stress response from trauma could be (wrongly) perceived by teaching staff and other professionals as ADHD. Brown et al. make a similar argument, noting that ADHD is often misdiagnosed because of a lack of professional enquiry into past trauma history (2017). This is why multiple studies (Hunt et al. 2016; McDowell 2017) conclude much more research is required on the link between ACEs and behavioural outcomes.

Attendance

Blodgett and Lanigan’s 2018 study looked at the link between ACEs and attendance in detail and found evidence that ACEs was a strong predictor of attendance — with absenteeism increasing for each additional ACE. 15.8% of children with one ACE were predicted to have problematic school attendance, compared with 48.7% for those with four ore more ACEs (2018 p143).

Evidence on the link between ACEs and attendance is important because, as Stempel et al. point out, poor attendance is a strong predictor of poor educational outcomes overall (2017). Dube and Orpinas (2009) looked at the importance of regular school attendance to children’s positive development and the risks associated with regular absenteeism and concluded that understanding the underlying causes of that behaviour is critical in finding interventions to combat it.

The reasons for the link between absenteeism and ACEs are manifold, often directly linked to the trauma itself (Iachini 2016) or with the effects — predominately internalised behaviours, such as mental health or anxiety which lead children to actively avoid school (Stempel et al. 2017). Like other aspects of ACE impact, studies have found it is the number of ACEs, rather than the type of experience itself which is the indicator of absenteeism. Only one ACE has been identified to have a statistically greater significance on attendance which is around witnessing violence in the community (ibid.).

Studies have also shown that absenteeism as a result of ACEs could result in a cycle of increasing adversity, as those who are not attending are at greater risk of negative health and social problems, which further embed the internalised behaviours which created the absenteeism in the first place (Dube and Orpinas 2009). This cycle of absenteeism can lead to complete exclusion (either self-exclusion or forced exclusion) from learning. Iachini et al. (2016) studied ACEs within the context of school dropout prevention and found that those children who were most likely to exclude themselves from education were those who had the greatest experience of childhood trauma. This research suggested a number of ways schools could combat absenteeism, including creating more friendly school environments and becoming trauma informed — recognising absenteeism within the context of the experiences the young people had been living through (ibid.). This approach is critical because research has shown that the generally recognised determinants of absenteeism such as poverty or special health care needs have less of an impact than ACEs across the board (Stempel et al. 2017).

Research into ACEs, absenteeism and the impact on learning is limited. The work by Stempel et al identified the relationship between higher ACE score and “chronic absenteeism” (p842) but noted that this “finding is novel, as prior literature has only found a relationship between higher ACE score and grade repetition or poor school performance” (ibid.). As with other studies (Blodgett and Lanigan 2018; Mersky et al 2017) there is a call for further research into the specific link to allow evidence-based interventions to be developed.

Attainment

Much of the research on ACEs focuses on the social and emotional impact of trauma on children, and where it does look at outcomes in childhood, focuses on behaviour and absenteeism. There is much less research looking at the direct impact on educational attainment within the school setting (McDowell 2017; Blodgett and Lanigan 2018). Some studies have looked at the impact of ACE academic outcomes, for example studying the impact of mental health as a result of ACEs on grade performance (Porche et al. in McDowell 2017). Morrow (2017) concluded that there was a gradated link between ACEs and attainment — the more adverse experiences in childhood, the poorer the educational outcomes will be. Her research goes on to find evidence of a specific impact on reading, with a link between ACEs and lower reading ability at age 16.

Bethell et al. (2014) also reviewed the number of children who repeated a year at school by the number of ACEs they had and found that those with two or more ACEs were 2.67 times more likely to do so. As with similar studies, even taking into account other environmental and familial factors, there remained a strong correlation. Blodgett and Lanigan (2018) found similar results when looking directly at school success in elementary school children. Their findings around academic outcomes found a link between number of ACEs and reading ability for example, concluding that the multiple layers of adversity faced by some children directly links to poorer academic performance.

Some concluding thoughts

There is a growing body of research looking at adverse childhood experiences and their immediate impact on children rather than just the long-term health implications in adulthood. Multiple studies point to the link between ACEs and engagement with learning — Bethell et al for example demonstrating that children who had not experienced such adversity were 2.59 times more likely to always engage with school (2014).

For teachers, the implications of this — on attainment, attendance, behaviour or social and emotional behaviour are crucial to understanding the young people sitting in front of you. However, it is even more important to understand that ACEs are not indicators of fixed outcomes — they identify an increase likelihood on a population level, not an individual level.

The ACEs research doesn’t point to inevitability.

The ACEs research doesn’t mean because certain children have had certain experiences then their outcomes are going to be a certain way.

The ACEs research cautions against making any decisions about services a family needs or levels of risk using ACE ‘scores’.

The ACEs research recognises that two young people could have the exact same number of ACEs and have completely different outcomes.

The ACEs research recognises that one adverse childhood experience could be more significant than six for another child. The “intensity, frequency and chronicity” are what determines the impact. (Anda et al).

As Hunt et al make clear, there is a need for more research looking at the direct impact of ACEs on young people during their childhood development, not just the predicted outcomes in adulthood (2017). Given the relative lack of research in Scotland, despite considerable political interest, there is an opportunity for further study of ACEs and the attainment gap in the Scottish context.

In the meantime, I think we need to be much more careful at the way the ACEs research is being explained to future and current teachers, and ensure the misunderstandings (ACEs scoring, inevitability of outcomes etc) do not creep into everyday practice.

Closing the attainment gap requires a truly holistic approach for all young people — not least for those areas of children’s lives where ACEs do not cover (poverty being the key one that’s missing entirely). Complexity in the research is not a negative to be swept aside, but a positive to encourage deeper understanding of the nuances of young people’s lives.