Keywords: Adverse Childhood Experiences; Child maltreatment; Therapeutic interventions; Modular approach to intervention
There is a growing body of research on the nature of adverse experiences in childhood (ACEs). In 1998, Felliti and colleagues examined the relationship between the number of ACEs reported by more than 17,000 individuals in the USA and their subsequent health as adults. They found the more ACE types reported in childhood (e.g. emotional abuse, physical abuse, sexual abuse, physical neglect, emotional neglect, mother treated violently, household substance abuse, household mental illness, incarcerated household member, and parental separation or divorce) the greater the risk of health harming behaviours. These harmful effects include adult mental ill health, problematic alcohol use, and sexual risk taking. The associations with number of ACEs reported are strongest for problematic drug use and interpersonal and selfdirected violence (Hughes et al., 2017).
There is also a growing body of research demonstrating that young people displaying challenging disruptive, bullying and sexually harmful behaviour, and associated significant mental health difficulties have suffered multiple ACEs. These findings justify the argument that early intervention with this group of children and families would prevent later harm [1,2].
Harmful impact of ACEs
The most harmful responses of children are associated with exposure to violence against a caregiver, and the presence of a parent with a mental health or substance problem . There are protective factors which are independently linked to better outcomes - being treated fairly, having supportive childhood friends, being given opportunities to use own abilities, access to a trusted adult and having someone to look up to  which suggests that appropriate intervention could be effective in promoting children’s resilience. On the basis of an extensive review of all the evidence from 37 studies describing 253,719 individuals, Hughes and colleagues (2017) argue that ACE-informed practice can (should) be developed across multiple settings, including schools, social care and criminal justice agencies, and, in contexts of concern when children are showing evidence of being subjected to maltreatment, with associated parental mental health and substance abuse.
We have a growing understanding of the nature of ACEs and their impact. This knowledge, however, has not yet been translated into a systematic programme of early intervention designed to modify the impacts of ACEs when these are identified: The common core of interventions that build children’s social and emotional competency and strengthen parent-child interactions have not yet been developed. (Finkelhor 2018) points to the wide range of practitioner training needs arising from ‘domestic violence intervention to grief counselling, childhood aggression and substance abuse’ (p. 175). He argues that it may be better to develop a secondary preventative approach to intervene to modify the triggering of ACEs in family contexts characterised by harmful parenting, violence loss, mental health substance abuse and disruption, and to address the residual impact on children’s health and development. There are interventions to prevent the harmful impact of maltreatment through work with children and parents, however these approaches do not fit with the complex responses associated with multiple ACEs .
A Modular Solution
Reviewing the transdiagnostic neurobiological responses to multiple ACEs, a solution is proposed. It is based on the highly effective Modular Approach to Children with Anxiety, Depression, Trauma and Conduct Problems (MATCH-ADTC), which integrates common practice elements from single manualised effective approaches to these problems (Chorpita & Weisz 2009) [6,7]. The modular Hope for Children and Families (HfCF) Intervention Resources add to these elements from the field of interventions to prevent abuse and neglect – the core of the ACE problems . The HfCF Intervention Resources are a potential solution to help practitioners by providing a trauma-informed, transdiagnostic, modular approach, that can be adapted for use with multiple ACEs across different types of service provision at all stages of the therapeutic process .
The development of the HfCF Programme has prepared the groundwork for a programme to ‘Build children’s social and emotional competency, strengthening parent-child interactions. The HfCF programme is unique in that it is designed and positioned already to respond systematically to the sequelae of multiple ACEs. The practitioner can choose modules that best fit with the assessed needs of children and their families from nine intervention guides. Working with the family and parenting modules addresses many factors (abusive and neglectful parenting, family conflict, parental mental health and substance abuse, loss and incarceration) when ACEs are recognised in multiple settings. The HfCF interventions help practitioners strengthen the quality of family life; modify harmful parenting; and, promote positive parenting, warmth, security, and positive child development .
When working with a child and family, a thorough assessment is essential to identify ACEs, and to understand their impact and the processes that maintain them . A profile of the child, parent and families’ strengths and difficulties has to be established, the nature of the child’s impairment of health and development needs assessed, and patterns of harmful and potentially supportive responses identified in the family [12,13]. Prospects for intervention need to be analysed, including the motivation and capacity of parents to respond to intervention, and support direct work with children and young people to address emotional and traumatic and disruptive behaviour, including sexually harmful responses, associated with ACEs. The goal of the intervention is to promote recovery and resilience, and to prevent the long-term harmful effects on future adult health through adversity targeted early intervention.
- Flaherty EG, Thompson R, Dubowitz H, Harvey EM, English DJ, et al. (2013) Adverse Childhood Experiences and Child Health in Early Adolescence. JAMA Pediatriatrics 167(7): 622-629.
- Garcia AR, Greeson JKP, Thompson A, Denard C, Gupta M (2017) Adverse childhood experiences among youth reported to child welfare: results from the national survey of child & adolescent well-being. Child Abuse and Neglect 70: 292-302.
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- Bentovim A, Vizard E, Gray J (2018) Editorial Perspective: Treatment of complex maltreatment - beyond the NICE guideline? Manuals, muddles or modules. Child and Adolescent Mental Health 23(3): 297-300.
- Chorpita BF, Weisz JR (2009) Modular Approach to Children with Anxiety, Depression, Trauma and Conduct Match-ADTC. Satellite Beach FL: Practice wise LCC.
- Chorpita BFL, Daleiden EL, Park AL, Ward AM, Levy MC, et al. (2017) Child STEPs in California: A cluster randomized effectiveness trial comparing modular treatment with community implemented treatment for youth with anxiety, depression, conduct problems, or traumatic stress. Journal of Consulting and Clinical Psychology 85(1): 13-25.
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- Bentovim A, Gray J (2017) Hope for Children and Families: Building on Strengths, Overcoming Difficulties. York: Child and Family Training.
- Gray J (2015) Hope for Children and Families Intervention Resources Pilot Project. Report submitted to the Department for Education. York: Child and Family Training.
- Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, et al. (1998) Relationship of Childhood Abuse and Household Dysfunction to many of the leading causes of Death in Adults: The Adverse Experience (ACE) study. American Journal of Preventative Medicine 14(4): 245-258.
- Finkelhor D (2018) Screening for Adverse Childhood Experiences (ACEs) Cautions and Suggestions. Child Abuse and Neglect 85: 174 -179.
- Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, et al. (2017) The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health 2: e356-66.