Routine Enquiry About Adversity in Childhood - Implementation
Dr. Warren LarkinClinical Lead – Department of Health – Adverse Childhood Experiences Programme
Visiting Professor Sunderland University – Consultant Clinical Psychologist
@warren-larkin
www.warrenlarkinassociates.com
WhyamIhere?• 24yearsagoIstartedworkingwithpeoplewithseriousMHproblems,associatedsocialproblemsandpoorhealth.
• Inoticedthatdespitehavingdifferentdiagnoses,labelsandcomingfromdiversebackgrounds;theyhadtwothingsincommon:
• Theydidn'tseemtobegettingbetter• Theyallhadexperiencedsignificantadversityandtrauma
• Ihavespentthelasttwodecadesworkingwithindividuals,families,organisationsandgovernments;withthemissionofmakingitokforpeopletotelluswhathappened tothem
• Idothisbytrainingprofessionalshowtoaskappropriately• Andbyhelpingcreatetraumainformedservices
The5areasofACEScience?ACEssciencereferstotheresearchontheprevalenceandconsequencesofadversechildhoodexperiences,andwhattodotopreventthem:1. Theepidemiologyofadversechildhoodexperiences(ACEs)
• In the English National ACE study, nearly half (47%) of individuals experienced at least one ACE with 9% of the population having 4+ ACES (Bellis et al 2014.)
• There is a casual and proportionate (dose-response) relationship between ACE and poor physical health, mental health and social outcomes (Skehan et al 2008; Kessler et al, 2010; Varese et al 2013; Felitti & Anda, 2014.)
ACEScience
2.Brainscience– (theneurobiologyoftoxicstress)• Toxicstressadverselyaffectsthestructureandfunctioningofachild’sdevelopingbrain
3. Healthconsequences• ToxicstresscausedbyACEs affectsshort- andlong-termhealth,andcanimpacteverypartofthebody,leadingtoautoimmunediseases,suchasarthritis,aswellasheartdisease,breastcancer,lungcancerandarangeofmentalhealthproblems.
ACEScience
4.Historicalandgenerationaltrauma- epigeneticconsequencesoftoxicstress• ToxicstresscausedbyACEscanalterhowourDNAfunctions,andthatcanbepassedonfromgenerationtogeneration
Notonlyasking:"Whathappenedtoyou?",alsoasking"Whathappenedtoyourparents?"Toyourgrandparents?Toyourgreat-grandparents?Toyourtribe,ethnicgroup,etc.?• RachelYehudastudiedtheoffspringofholocaustsurvivors• Theyhadalteredstresshormoneprofilesmakingthempronetoanxietydisorders
ACEScience
5.Resilienceresearch-Thebrainisplasticandthebodywantstoheal.• Trauma-focusedtherapies,E.g.,TF-CBT,EMDR,bereavementcounsellingetc.
• Traumasensitiveschools– Therearemanyexamplesofhowintegratingtrauma-sensitive&resiliencebuildingpracticesinschoolscanresultinfewerexclusions,lessviolence,bettertestscoresandgraduationrates.
TheKaiser/CDCACEStudyreportedsomeastonishingfindings
1. ACEsarecommonand64%ofadultsreportedatleastone.2. ACEscauseadultonsetofchronicdisease,suchascancerandheart
disease,aswellasmentalillness,violenceandbecomingavictimofviolence
3. ACEsdon’toccurinisolation– ifyouexperienceoneACEthere isan87%chancethatyouwillexperiencetwoormore.
4. Thereisa‘Dose-Response’relationshipbetweenACEsandlaterlifeoutcomes- PeoplewithanACEscoreof6orhigherareatriskoftheirlifespanbeingshortenedby20years.
5. ACEsaccountforalargeproportionofabsenteeismfromwork,andforcostsinhealthcare,emergencyresponse,mentalhealthandcriminaljustice.
Latest Findings From Vincent Felittiand Centre for Disease Control
ACEs Adverse Childhood Experiences
The ACE studyis still an ongoing collaboration between the CDC and Kaiser’s Dept of Preventative Medicine in San Diego
More recent findings:
6 ACEs increased the risk of becoming an IV drug user by 46 times
6 ACEs increase the risk of suicide by 35 times
BIRTH
Adverse Childhood Experiences ACEs- The Life CourseDEATH
LIFE
CO
UR
SE
Bellis 2016 Developed from Felitti et al. 1998
Early Death
Non Communicable Disease, Disability, Social Problems, Low Productivity
Adopt Health Harming Behavior's and Crime
Social, Emotional and Learning Problems
Disrupted Nervous, Hormonal and Immune Development
ACEs Adverse Childhood Experiences
ATrauma-InformedApproach
• "Whathappenedtoyou?"insteadof"What'swrongwithyou?"
• Itisdesignedtoavoidre-traumatising alreadytraumatised people
• Ithasafocuson"safetyfirst"(includingemotionalsafety)
• Includesacommitmenttodonoharm.
Creatingtheconditionsforsustainedpracticechange• TheconceptualmodelorcausaltheoryheldbytheorganisationandItsworkforcewilldeterminewhatquestionsareasked
• Iftraumaandadversityisnotseenasfundamentaltotheindividual'scurrentdifficulties– theprofessionalwillbeunlikelytoaskaboutit
• E.g.,apsychiatristwhobelievespsychosisisabraindiseasecausedbyfaultybrainchemistry,whichisgeneticallydetermined– theyareunlikelytoaskabouttraumaandadversity
• Childhoodtraumaisacausalfactorinpositivepsychoticphenomenaandspecificallyhallucinations.
Childhoodtraumaandpsychosis:evidence,pathwaysandimplications.LarkinW,ReadJ,(2008)jpgmonline.comSkehan,Larkin&Read(Psycho-analysis,Culture&Society(2012)17,373–391)
Askingabouttrauma:theexperiencesofpsychologicaltherapistsinearlyinterventionservicesToner,J.,Daiches,A. &Larkin,W. 2013In:Psychosis.5,2,p.175-18612p
PERSONAL MODEL
OF PSYCHOSISDeveloped via clinical experience, links to literature,
Utilised by formulation, benefits to clients, makes sense, role of therapist, Trauma, developmental models,
PROCESS OF ASKING/SKILLSDO’S, DON’T, STYLE, INTUITION, SPECIFIC QUESTIONS, REHEARSAL,
OBSTACLES, TOOLS
CommitmentSupervisorService structureLiteraturePeople/championsPlacesPracticeStill a long way to go!
CHANGING SERVICE CULTUREPre-EI-Historical-Barriers-Pre EI concerns-Barriers/modesty-Pseudo EI-Historical??-Negative view of EI-Current within service-Rationale-
Outside EI-Problems with EI
The case for routine enquiry in health and social care
Waiting to be told doesn’t work…
Victims of childhood abuse have been found to wait from between nine to sixteen years before disclosing trauma with many never disclosing
(Frenken & Van Stolk, 1990; Anderson, Martin, Mullen, Romans & Herbison, 1993; Read,
McGregor, Coggan & Thomas, 2006
Read and Fraser (1998) found that 82% of psychiatric inpatients disclosed trauma when they were asked, compared to only 8% volunteering their disclosure without being asked.
Felitti & Anda (2014) report a 35% reduction in doctor’s office visits and 11% reduction in ER visits in a cohort of 140,000 patients asked about ACEs as part of standard medical assessment in the Kaiser Health Plan
RoutineEnquiryaboutViolence&Abuse(REVAStudy2015)• Reviewimpactofpolicyonroutineenquiry10yearsonfromitsintroduction- returningtofouroftheoriginalpilottruststoconductqualitativecasestudyresearch
• Toexploreindepththelessonsthatcouldbeextractedfromtheirexperience.
• Interviewsconductedwithseniorandstrategicmanagers,secondaryandprimarycarepractitionersinvolvedintheimplementationofroutineenquiry(RE)andserviceprovidersfromthevoluntarysector
• Serviceuserswhohadexperiencedinterpersonalviolenceandabusewerealsointerviewed
RoutineEnquiryaboutViolence&Abuse(REVAStudy2015)
Thetwokeyfindingsconcerningroutineenquiryaboutexperienceofviolenceandabuseaspartofmentalhealthassessmentare:
1. Routineenquiryisacceptabletoandconsidereddesirablebysurvivors.
2. Routineenquirycanbeeffectivelyembeddedinpracticewhere:
RoutineEnquiryaboutViolence&Abuse(REVAStudy2015)• Thereisstrategicleadershipandcommitment• Overallresponsibilityforimplementationisallocatedtosomeonewithsufficientauthorityandlocalresponsibilityisdelegatedtomanagersandclinicalleadsineachservice
• Itisregardedasanintegralaspectofsafeguarding• ‘Thequestion’isincludedinallrelevantassessmentdocumentationandinclinicalaudit
• Adequatetrainingisprovided• Staffhaveaccesstospecialistadviceandsupervisionwhenrequired
REACh Model
Readiness Checklist and organisational
‘buy in’
Change ManagementSystems and processes to
support enquiry
Training StaffHearts and
minds & how to ask and respond
appropriately
Follow-up support
And supervision for staff and
leadership team
Evaluation and Research
REACh implementation across settings & agencies
LCFT South East Team and Health
Visitors
Blackburn with Darwen Children’s
Services Family Support Team
Greater Manchester NHS Foundation Trust Substance Misuse Service
Evolve (Substance Misuse Service)
Child Action North West,
Familywise TeamLifeline, Substance
Misuse PractitionersW.I.S.H.
(Domestic Abuse)Women’s Centre
(Counselling, Support and Employment)
LessonsfromImplementation
• “LifelineembeddedtheuseofRoutineEnquiryintoAdverseChildhoodExperienceswithinholisticassessmentaspartofapilotproject.Thiswasfollowingeffectivetrainingforstaff,tosupportthemthroughthisprocess.TheteamfoundthatREACHenabledyoungpeopletodiscloseandreceivesupportatanearlieropportunity.Practitionersfeltsupportedthroughoutandfelttheywerebetterabletosupportyoungpeoplewhilstunderstandingthecomplexitieswithintheirlives.”
ZoeGatland,Manager– Lifeline– YoungPerson’sD&Aservice
LessonsfromImplementation
• “Cultureshiftneeded- poorMHserviceslocallymeanitishardtosupportclientsafterwardsiftheyneedspecialistinput”
• “Clientswhoarealreadyawareandwantingtodealwithpasttrauma,withsupportdoreallywellwiththesupportoftheirworker”
• “Fullboroughapproachwouldbehelpful– makingsurepartnersareonthesamepageandreadytoplaytheirpartinrespondingtosomeone’sneeds”
• “REAChisimportantbutitisimportantforstafftoknowwhenisbesttimetoaskthequestions” JackieMcVann,ServiceManager,CGL
• ’Ifdonewell,withcarefulplanning,seniormanagementunderstanding& drive,spaceforreflectionandstaffdevelopment,andanoverallframework,REAChcouldbebeneficialinthecareforvulnerablepeople. Inadditionitwouldsupport:
• Earlyinterventionandrecognition• ChangingIntergenerationalbehaviours• Recognitionofcause,andseekingtreatmentandhelp• Self-awarenessandfamilyrelationships• Akinder,moreempathicandopencommunity– liketheMHmovement– inrelationtopeersupport,openconversations,personalunderstanding’.
• JackieMcVann,ServiceManager,Change,Grow,Live.
LessonsfromImplementation
• Revisitingthelearning5yearson:
• “Formeasafrontlinememberoftheteamithastobethatsincetheintroductionof RE/ACEithasreallyinfluencedthewayweworkandsupportthefamilies.Onceyouhavetheinsightintotheimpactofityoucan’tun-seeitanditisattheforefrontofyourmindassoonasyouhavebeenallocatedanewfamily.Ithasbeenembeddedintoallofourplansandrecordingsandbecomessecondnature.”
• PaulineWellbank - EarlyHelp- FamilySupportTeam- Blackburn-with-Darwen
TheRoutineEnquiryintoAdversityinChildhood(REACh)Project• Pilotproject
• 4sites:Practitionersworkingwithyoungpeople,familiesandchildreninoneNHSsite,oneLocalAuthorityservice,andtwofromthecharitablesector
• ACEAwarenessTrainingaimedto:• developconfidencetoroutinelyaskaboutadversity• increaseknowledgeandawarenessofthepotentialconsequencesofadversity
• developskillsinrespondingappropriatelytodisclosuresofadversity,includingappropriatereferrals
• Expectedtoembedroutineenquiryintotheirdailypractice
AimofStudy• ToexploretheexperiencesofpractitionerswhohadreceivedtheACEtrainingandwereroutinelyenquiringaboutadversity
Method• Semi-structuredinterviewswith7practitioners• ThematicAnalysis(Braun&Clarke,2006)
Participants• 3HealthVisitors(NHS)• 1DrugandAlcoholSupportWorker(Charity)• 1FamilySupportWorker(Charity)• 2FamilyWellbeingPractitioners(LocalAuthority)
Results• 5mainthemes
Theme1:ChangeinKnowledge,PerceptionandPractice•Therewasarangeinhowmuchthetrainingimpacteduponchange:
• PriorexperienceofconsideringACEsinpracticepredictedlesssignificantchangeinknowledge,perceptionandpractice:
• “It’sjustabout…tryingtoseekoutiftheyhadanytraumasordifficultiesintheirchildhoodthatthenaffecthowtheyparenttheirchildren,sowealreadydidthat,andwealsohadroutinequestioningwhich,again,isroutineforourservice”
• Thosewithnopriorexperiencedescribedmoresignificantchanges:
• “Idon’tthinkthatwithouttheknowledgeoftheACEquestionsandthescoresIwouldhavepickeduponthoseissues”
Theme1Continued…
•Changetowardmoreadversity-informedunderstandingofclients’difficulties
“Itweregoodforustounderstand,whentheseadversechildhoodexperienceshappentosomebody,howitdoesgoontoleadtoalcoholuse,mentalhealthproblemsandthingslikethat,soitmadeusmoreaware”
• Thisleadto:• Increasedself-reportedreferralstocounselling• Ledtotherapeuticconversationswithclients• Changesinperceptionofclients“IthinkbecauseIknewaboutthoseACEquestions,Iknew
wheredadwascomingfrom,ratherthandadjustbeingadifficultparent,wellitjustmademoresense”
Theme2:TheEmotionalImpactofHearingandRespondingtoDisclosure• Participantsspokeofaninitialconcern
• feelingtheymightbe“openingacanofwormsthatwecan’tdealwith”,andfeelingconcernedthat“we’regoinginandthey’rebringingupalotofstuffandsomeofithasbeenverytraumaticforthemandthenwe’redoingthatandthenkindofleaving”
• However,themajorityofparticipantsneverfelt“unabletosupportsomeone”,andformostparticipantsthiswasaninitialconcernthatdidnotmaterialise:“formethatwasaworrybutthathasn’thappened”
• Oneparticipantstruggledemotionally• Hearingdisclosuresfeltlikea“lostworld”andfeltthatdisclosuresbecamea“burden”tohim.Thisparticipantfeltitdifficult“tomoveonfromthatafteryou’veclosedthesession”
Theme2Continued…•Majoritytalkedaboutpositiveemotionalimpact
• Participantsspokeaboutfeeling“moredeterminedthatIamgoingtohelp”,andfeeling“honouredandblessedthatI’vebeentheretogetthemthroughwhateverthey’regoingthrough”
•Adversity-informedunderstandingdrivingmotivation:“Ithinkthatjustgivesyouthatdrivetokeep
going…I’vetakenfivestepsforwardandfivestepsback,youknow,andIthinkwhereyoukindofgo,whyamIbothering,youknowwhyyouarebotheringand youknowwhyitmatters”
Theme3:ConfidenceinAskingandRespondingAppropriately
•Participantstalkedaboutconfidenceinrespondingtodisclosure
• Knowingwheretoreferpeople• Andconfidenceknowingwhenareferralisn’tneeded:
“forsomeclientsitjusthelpstotalkabouttheirexperiences”
•Oneparticipantfeltlackofconfidence:“Idon’thavetheconfidenceto,and…Igetquiteemotionalaboutthis
kindofstuff,andnotknowingwhattodo,it’sworsethan,Idon’tknow,it’sworsebecauseIdon’tknowwhattodo”
Theme3Continued…• Levelofconfidenceseemedtobepredictedby:
• Managementsupport:• “wehavealwaysgotourmanagerstheredaily,andyou’dneverholdonto
anythingyourself”• Clinicalsupervision:
• “clinicalcasesupervisionreallyuseful”• Peersupervision:
• “Weareallouttheredoingit,andit’slikepeersupervision,andIthink,yeah,it’sgreattohavetheexpertthere,toalsohaveyourpeersandtobeabletosharegoodpracticeandtosayyeahweareouttheredoingit,weareonthefrontlineandweareactuallyaskingthequestions,Ithinkthatisreallyuseful”
Theme4:MakingSenseoftheImpactofDisclosureforClients
• Participantsfeltitwasimportanttohelpparentsto“understandwhat’shappenedtothemintheirchildhood,ifwecanstopthemrepeatingthoseissuesthenhopefullywecanmakeabetteroutcomeforthosechildren”
• Therapeuticconversationswereoftendescribedasdramaticandinvaluable:
“Ihadamumtheotherweekandshesaid,noIwerebroughtupfine,andthentheweekafterIsawherandthelittleboywerestrugglingand
Isaid,howdidyourmummanagewithyou,andshesaid,ohshejustusedtosendmeupstairs,shejustusedtoignoreus,andIsaid,heylastweekwhenyousaideverythingwerefineanddandy,howdidyoufeelwhenyourmumusedtojustsendyouupstairs,andshewent[lightbulbmoment],andIcouldseeitinhereyes…sheknewshe’dbecomehermum”.
Theme5:HowandWhentoAskAboutAdverseExperiences•Usingclinicalintuitiontodecidewhenappropriate• Importanttoexplainwhyaskingthequestions
• Sometimesenoughtopromptdisclosures• Forsome,importanttodeveloptherapeuticrelationship• Touseadaptivelanguage• ConversationalversusStructuralstyleofaskingquestions• Revisitingthroughouttheirworktohelppeopletomakelinks
“Ithinkit’sjustaboutpersonality,buildinguparelationship,bodylanguage,wheretheyareandbeingconfidentinhowyoudoitandwhyyouaredoingit,reallyfocussedonwhyyouaredoingit,andIdon’tthinkyoucouldmakeitanyotherway”
Discussion
• ConsistentwithToneretal.(2012)• ItistheshifttowardmoreACEinformed,formulationdrivenunderstandingofclients’difficultiesthat:
• Increasedempathicunderstanding• Ensuredcommitmenttoroutineenquiry• Increasedself-reportedreferralstocounselling• Ledtotherapeuticconversations
• IncontrastYoungetal.(2001)• Clientsdidnotexperiencedistressasaresultofbeingasked• Majorityofstaffdidnotexperiencedistressasaresultofhearingdisclosure
• Predictedbypeersupervisionandmanagementsupport
“It’snotsuddenlychangedthirtyoddyearsofabehaviour…andithasn’tundoneallthoseexperiences,butithasmadethemquestionnow,whataremychildrengoingthrough...whatACEsamIputtinginfrontofmychildren,andIthinkit’sstartedthatjourneyforthem”
• Most participants were not aware of the impact of adversity on later life outcomes before the training.
• REACh training equips practitioners with the knowledge, confidence and skills to conduct routine enquiry with the people they support.
• Routine Enquiry is feasible and acceptable to staff and service users.
• There have been no reported significant increases in service need following practice change. Most service users are well supported by the worker they disclosed to or were currently working with.
• The REACh approach was the catalyst for increased frequency of disclosures, better therapeutic alliance and more targeted interventions.
• Following routine enquiry people report considering the impact of ACEs in relation to their own children.
• Routine enquiry can quickly become business as usual.
Key Findings
Thank you…
Please drop me a line!
@warren-larkin
www.warrenlarkinassociates.com
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