When four ACEs is a bad hand

Introduction by Iain Smith

Spending 25 years reading social work criminal justice reports as a defence lawyer, you regretfully come to expect many of your clients to have a backstory that seems to explain, if not mitigate, how they reached a point in their life that finds them in court.

People with troubled backgrounds do not inevitably end up in court, but a seminal study explains the biological science of why it becomes more likely. Identifying adverse childhood experiences, known commonly by the acronym ACEs, allows those dealing with people who have experienced trauma to better understand their background and provide assistance.

Numerous organisations and individuals throughout Scotland are now shouting about ACEs, in order to raise awareness of this science. Discussion has been ongoing for the past decade within Scotland, but the last year has witnessed the emergence of a dynamic grassroots movement advocating for change. Organisations such as the Scottish Violence Reduction Unit, NHS Health Scotland, any number of schools and even private businesses are working to alter society’s understanding of the behaviour that can come from trauma. Calls to prevent ACEs in the first place are growing louder.

Dr Suzanne Zeedyk, developmental psychologist and research scientist, based for 20 years at the University of Dundee, has been at the centre of the growing ACEs movement in Scotland. She has kindly agreed to explain the science and illuminate its relevance for the legal community.

What are adverse childhood experiences?

Adverse childhood experiences (ACEs) are exactly the sorts of events that defence lawyers, prosecutors and judges repeatedly find described in background reports. “X advised that she was removed from her mother’s care at the age of nine, having witnessed multiple instances of violence between her mother and various partners. Drugs and alcohol were frequently present in the home. She was placed in foster care, experiencing three different placements by the age of 16.”

Events such as these cause children distress, fear and loss. Stress changes human biology, and stress in childhood yields long-term biological consequences. That is the conclusion of the seminal Adverse Childhood Experiences Study, published in 1998, but which has taken two decades to reach public awareness.

The key finding to emerge from the study, which involved a massive 17,000 participants, was that the greater the number of stressful events (ACEs) a person had faced as a child, the greater the likelihood of health problems in adulthood. These included heart disease, liver disease, type 2 diabetes and pregnancy loss. Behaviours that put health at risk also increased, including smoking, drinking and illicit drug use. These sat alongside increased likelihood of mental health struggles, such as depression and suicide.

The 10 ACEs on which the study focused were: physical, emotional or sexual abuse; physical or emotional neglect; parental mental illness, substance use or incarceration; mother being treated violently; and parental divorce. Although many other ACEs are possible, these 10 provide a good initial measure of trauma within the general population. The study’s results robustly confirmed that the higher a person’s ACE score, the greater the risk that they would encounter poor health outcomes in adulthood. A score of 4 or more signals a step-change in the risk of poor outcomes, as hinted at in the title of this article.

For example, one recent research study (Balgilvio et al, 2014) focusing on young people in the criminal justice system unveiled a prevalence of ACE scores of 4+ at four times greater than that found within the general population.

The biology of trauma

How do we explain the study’s findings? The answer lies in understanding human biology, including the growth of neural pathways in the brain and the development of the body’s self-regulatory system. Both are immature at birth, and infancy and childhood are the periods in which the associated biological changes occur most rapidly and become most embedded in an individual’s physiology. Researchers working in the field of ACEs have now developed a model that explains how neurological and physiological changes underpin adult behaviour, disease and early death.

This model enables us to recognise that the actions seen so frequently within the criminal courts often originate from a fragile self-regulatory system. If a brain perceives a situation as threatening, frustrating, overwhelming, accompanied perhaps by a sense of impending emotional loss, levels of the stress hormone cortisol spiral. This happens even more rapidly in a person who has a history of trauma, given that their “cortisol switch” is set on a kind of permanent overdrive. Cortisol makes it difficult for you to think clearly. Your brain and body quickly, even instantaneously, enter into flight-fight-or-freeze mode. People with a high ACEs score can spend 24 hours of every day in that mode, never moving out of it.

A fragile self-regulatory system, or what I metaphorically refer to as an “internal teddy bear”, makes it difficult for a person to comfort and calm themselves in the midst of intense emotions. That leads to precisely the kinds of actions that land people in the courts. It leads to the kinds of actions that a person may later regret, even if they find themselves regularly behaving this way. It leads to the kinds of coping mechanisms that reduce agitation, but that have negative health outcomes, including smoking and overeating. It leads to the kinds of actions that bring suffering into one’s own life and into the lives of others. In short, children do not bounce back from “troubled childhoods”. Childhood stress, fear and loss leave long-term biological wounds. 

Toxic stress

So why are individuals not equally affected by stressful events? We all know people who survive, for example, domestic violence in their childhood, but who do not react violently toward their partners. It is this question that has led researchers to develop the concept of “toxic stress”.

Stress becomes toxic for all of us if we have no one to whom we can turn for help. This is especially the case for children, with their immature self-regulatory systems, who are simply incapable of self-regulating without help. Self-regulatory systems become warped when an environment places a child under extreme and irresolvable emotional pressures.

ACEs thus become toxic when children are left to deal with fear alone, without an adult to whom they can reliably turn for help. The research literature shows that the key element allowing individuals to “survive” a troubled childhood is having one reliable adult in their life. That adult provides a haven of safety and co-regulation. It is a sobering thought to reflect on the number of children in our society whose lives are absent of even one emotionally reliable adult.

I use the metaphor of “internal teddy bears” because we all instinctively understand the comfort provided by external teddy bears. Ironically, our society and its institutions (e.g. schools, social work, childcare, families) often overlook, misunderstand or discount the anxiety children feel. ACEs become more common in a society that fails to recognise the stressors within children’s worlds or facilitate responsive relationships. The fact that the UK regularly ranks near the bottom in international surveys of childhood happiness should give us pause for serious thinking. 

Making excuses?

One of the concerns that the ACEs Study raises is whether this knowledge could be used to propagate excuses for “bad behaviour”. If we respond to criminal actions with curiosity and compassion, does that mean we are somehow condoning them? Is blame, shame and punishment not the appropriate reaction for inappropriate behaviour? Such questions point to underlying philosophical and moral debates that go to the heart of our justice system and our Scottish culture.

Once we comprehend the biological impact of trauma, we become able, if we wish, to rethink aspects of that justice system. To what extent should all members of the legal profession, civil and criminal specialists alike, be trained in ACE awareness? Should evidence of ACEs be taken into account as mitigating factors at the time of sentencing? Does prosecuting people for illegal drug use make good sense, once we understand that such use functions as a self-regulatory strategy? If we are to stamp out domestic violence, should greater emphasis be placed on strong preventative support services for families, alongside prosecution for violence?

The science of ACEs has the potential to help us rethink aspects of the criminal justice system in our society, especially if we wish Scotland to be, in the words of our Government, “the best place to have grown up”. 

The ACEs movement in Scotland

There is now an active ACEs movement under way in Scotland, involving both policy action and a burgeoning grassroots community.

Examples of the policy and political response can be seen in the establishment of the multidisciplinary Scottish ACEs Hub, hosted by NHS Health Scotland. The Hub has drawn strategic confidence from efforts already underway in England & Wales in regard to ACEs, and attention in Northern Ireland is now accelerating. ACEs feature explicitly in the Scottish Government’s 2017-18 programme; and are explored in a new Government publication on ACEs and justice. Earlier this year, a cross-party working group on ACEs was established within the Scottish Parliament, under the leadership of MSP Gail Ross.

The grassroots movement emerged last summer, sparked by a series of screenings of the documentary film Resilience: The Biology of Stress and the Science of Hope. Produced by the production company KPJR Films and released in the US in 2016, the film tells the story of the ACEs Study and highlights the impact that informed action is having on communities in the US, both in terms of life outcomes and in economic savings.

The film was first screened in Scotland in April 2017, hosted by two small independent organisations, connected baby and Reattachment (supported by NHS Health Scotland). Their initial screenings led to an explosion of requests for the film, with attendees returning to their organisations and local councils, insisting that licences for the film be purchased and screenings be held for staff. Individuals and community groups have taken that responsibility upon themselves, hosting screenings in order to ensure that communities become informed. One year on, it is impossible to estimate how many hundreds of screenings of this groundbreaking film have been hosted and how many tens of thousands of Scots have viewed it.

Scotland is now witnessing the establishment of local ACEs hubs, in communities across the country. They are founded spontaneously by individuals or organisations who decide to take a lead in their local areas. The network of hubs are learning from each other how best to reach the public. Notably, the West Lothian hub has benefited considerably from the involvement of Iain Smith, of Keegan Smith Defence Solicitors. It is the only ACEs hub, to date, which has developed strong links with the legal profession.

Carol Craig, director of the Centre for Confidence and Well-being, has taken the debate further by turning an ACEs lens on Scottish culture, and its enduring history of alcohol, violence, drugs, poverty and poor health. Many of these issues, of course, intersect directly with the legal and court systems. In her new book, Hiding in Plain Sight (2017), Craig comes to a stark conclusion: Scotland raises its children harshly. That is not done intentionally or consciously, but is simply a cultural norm. Indeed, it is the very familiarity of that harshness that allows it to “hide in plain sight”, instantiated within the criminal justice system, our schools, our childcare settings, our social work policies and in our family interactions. Truly tackling ACEs in Scotland will require adults willing to engage in the same kind of courageous reflection that drove Craig to write her book.

One event that can assist with such reflection is the major ACEs conference being held on 25 and 26 September 2018, hosted by two independent organisations who work to support the needs of children and young people: connected baby and TIGERS. The title of the event paints a national vision: Making Scotland the World’s 1st ACE-Aware Nation. Paediatrician Dr Nadine Burke-Harris, who has become a global campaigner for ACEs and who features in the Resilience film now seen by so many Scots, will serve as the keynote speaker. More than 1,250 people are expected to attend on the two days. The significance of the event lies in the fact that it has arisen from and been embraced by grassroots energy. There is a growing sense of optimism in Scottish communities that we can tackle some of our most intractable societal challenges.

Join us!

The main purpose of this article has been to inform the Scottish legal community about scientific developments that can help in their work with clients. A secondary purpose is to invite members of that community to join us in the growing ACEs movement. Its core aims are the same as those of the legal system: social justice and a fairer society.