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Adverse childhood experiences can cast a lasting shadow over the lives of children and young people, that is why it is crucial they receive early help and support."

Imran Hussain, Director of Policy and Campaigns, Action for Children

Adverse childhood experiences such as abuse or neglect can have long-lasting effects on people’s lives. Young people may struggle to develop socially and academically as a direct result; they are at increased risk of physical and mental health problems both at the time and years later.

But poor outcomes are not inevitable and early intervention can make a difference.

Recent NIHR research aims to improve the lives of children and young people exposed to adverse childhood experiences. It identifies the types of support young people feel they need from services, and offers ways to support the mental health of children in care and those adopted from care. 

This Collection brings together examples of published NIHR studies, along with ongoing research, to highlight the NIHR’s increased investment in this important area.

Supporting the mental health and wellbeing of children and young people exposed to adversity should be at the heart of future research into Children's Social Care. This Collection is an excellent example of NIHR's investment in this important agenda to build a more robust evidence base that can be translated across the children’s social care sector.”

Fardawza Ahmed, Senior Programme Manager, What Works for Children’s Social Care

Impact of adverse childhood experiences

Adverse childhood experiences are highly stressful events in which a child is harmed directly, or lives in an adverse environment. They include physical, sexual or emotional abuse, neglect, and living in a household with parental mental health problems, domestic violence or substance misuse. These experiences increase the likelihood that children will have poorer mental and physical health. They are more likely to struggle making friends and to underachieve at school. 

Adverse childhood experiences make children more vulnerable, but they do not inevitably lead to poorer outcomes; they affect each young person differently. Some children may be traumatised in a way that affects their development, learning, health and behaviour. Others, through protective factors such as a safe and secure environment and their own resilience, may not be.

Children at risk

The most disadvantaged people in society are the most likely to have had adverse childhood experiences. Research has shown that exposure to different types of adversity is strongly associated with harmful effects on health that last into adulthood

Nearly all children under local authority care, or adopted from care, will have had some adverse childhood experiences. The National Institute for Health and Care Excellence (NICE) states that abuse and neglect are the most common reasons for entering care. In 2020 in England, there were more than 80,000 children in care; about 45% of them have a diagnosable mental health disorder (compared to 10% for all children). These include conduct disorders, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), anxiety and depression.

The current review of children’s social care in England aims to ensure that children and young people get the support they need. Knowledge about adverse childhood experiences has influenced policy and practice across the UK but more needs to be done to prevent and respond to childhood adversity. Research can provide evidence on what works. 

Young people need emotional and practical support

Every child is unique and responds to adverse childhood experiences in their own way. The impact of these experiences is complex. It depends on a range of factors, including the circumstances in which the child lives, and how resilient they are. A recent review explored the kinds of services and support these young people said they need. 

The young people in this study had experienced different types of adversity, but they had common needs from services. They wanted emotional support from a trusted adult who showed empathy, was non-judgmental, and an active listener. They valued practical support to manage everyday challenges, and wanted their needs to be at the heart of services. 

The researchers reviewed the effectiveness of the interventions available. Most focused on psychological therapies for mental health; the best evidence was for cognitive behavioural therapy for people exposed to abuse. Few interventions addressed the effects of adverse experiences on social relationships, behaviours and other aspects of life.

Both of these reviews were part of a larger study which identified areas of mismatch between young people’s needs and the types of support they were offered. For example, young people described the importance of stability and continuity in the support they receive. This allows time to build their trust. However, many interventions were short-term, lasting just a few weeks, and were delivered by people otherwise unknown to the young person. 

These findings can help inform the design of services to better meet young people’s needs.

Many young people in care who self-harm find professional support unhelpful

Children and young people living in care are at greater risk of mental health problems, including self-harm, than those not in care. Improving young people’s mental health is a national priority and it is important to take account of their views. Recent research provides insights into the support that young people who self-harm find helpful. The views of young people with and without experience of the care system were included. 

Support groups were seen as especially valuable by those in care who self-harm. Yet only one in five had experience of them. This could represent an underused source of support. Most young people, whether in care or not, reported finding informal support helpful - including from friends, carers and pets. The researchers say that focusing only on professional services for self-harm ignores the importance of informal support. 

Young people in care were more likely to attend accident and emergency departments for self-harm than those not in care. However, many found the support unhelpful. Their views on child and adolescent mental health services (CAMHS) were mixed; almost equal numbers of young people ranked CAMHS as the most or least helpful. Further research is needed to explore the negative views of professional services and find ways to improve the services for young people.

Detailed information about life before adoption could help

Like those in care, most young people who are adopted from care have suffered adverse childhood experiences. They are at higher risk of poor mental health than the general population. Many will also have had unstable living arrangements. 

Recent research looked at whether children’s mental health improved after adoption, and whether it was related to adversity before being adopted from care. Findings showed that their mental health had not improved four years after adoption. Problems increased with the number of adverse childhood experiences young people had before adoption. The researchers recommend that adoptive parents and social workers should have as much information as possible about a child’s life before adoption. This could help identify possible mental health problems early.

Adopted children are more likely to have symptoms of post-traumatic stress than the general population. But post-traumatic stress is not a single condition. Some people feel emotionally numb (avoidance), others are jumpy and tense (arousal) or have nightmares and flashbacks (intrusive thoughts). 

A recent study found the type of early adversity adopted children lived through was linked to the type of post-traumatic stress they went on to develop. For example, children who had experienced multiple risks were most likely to show avoidance and arousal. Those who had experienced adversity in early life were more likely to have intrusive thoughts. These findings have implications for care planning for individual children. They suggest that adopted children need tailored support based on the types of adversity they have experienced.

Ongoing NIHR research will inform future care

Recognising the need to support children and young people exposed to adversity, the NIHR has a growing portfolio of research. Twelve examples of ongoing projects are highlighted within this Collection. Some look at new ways for professionals to work; others examine training and support to help carers improve the lives of young people. Many have a particular focus on children and young people’s mental health and wellbeing. 

Conclusion

Children and young people affected by adverse childhood experiences need support from services, delivered in ways they find acceptable. Research highlighted in this Collection makes recommendations. Support should be both practical and emotional. Service providers need to display empathy, be non-judgmental, and active listeners. Stability and continuity can help build trusting relationships.

Mental health services should reflect what young people find helpful. Mental health problems are much more common among those in care; nearly all will have had adverse childhood experiences, and their needs may be different from others’.  An example in this Collection suggests young people in care who self-harm value support groups. These groups are rarely available; providing more could help. Professional services are often seen as unhelpful by young people; including informal forms of support might achieve more.

Research currently underway could suggest more ways to improve the lives of children and young people who have had adverse childhood experiences. The examples of ongoing NIHR research in this Collection include new ways for professionals to work, training for carers, and interventions to improve mental health.  

Caring for children and young people who have had adverse experiences is complex. It requires support from health and social care services. This Collection provides examples from NIHR research that suggests ways to improve the support these children receive.    

Examples of ongoing research

New ways for professionals to work

  • Understanding the lives of young people living with adverse childhood experiences and designing better ways to improve outcomes. The ORACLE study (OveRcoming Adverse ChiLdhood Experiences, £1.2m), led by Kings College London, aims to understand the challenges facing children and families living in adverse conditions. It seeks to gain insights and strategies to tackle health inequalities in complex real-world settings.

Training and support for carers

  • A new approach to improve the wellbeing of children in care is being tested initially in the STrAWB study (Shared Training and Assessment of Well-Being for looked-after children: Feasibility study, £550,000). Led by the University of Oxford, the new approach was developed with foster carers, teachers, social workers, young people, and mental health experts. The study is investigating whether a large future study would be possible and acceptable. 
  • A training and support package for carers to increase the resilience of children who have experienced multiple adversities. This is the aim of the ASPIRE study (Adult-caregiver Supported Positive psychology intervention to Increase Resilience, £148,000), led by North and Suffolk NHS Foundation Trust. Resilience can protect some children from developing mental health problems after adverse experiences. 
  • Can training for personal advisers improve the support they give to young people leaving care? At 16-18 years old, young people leave local authority care in England but they can continue to receive support from a personal adviser until they are 25. Personal advisers often focus on practical issues like housing and money, but emotional and social problems also matter. A study led by NHS Bristol (Promoting good health in Care Leavers through training for Personal Advisors, £830,000) is developing a training course for personal advisers to see if it could help them better meet the needs of care leavers. 

Interventions to improve mental health and wellbeing

  • What helps or hinders young people in care from accessing recommended treatments for post-traumatic stress? This is being investigated by a collaborative project across five NIHR Applied Research Collaborations (Trauma-focused cognitive behavioural therapies for children in care). Evidence-based therapies can help young people with mental health needs in care, but most do not have access.

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Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

“It is good to see that it is now accepted that children are always traumatised to some extent by early bad experiences, though their behavioural responses and the different services required to meet these, will vary depending on individual personalities and circumstances.

Sadly, many of these children spend much or all of their childhood being looked after by people with whom they have no blood relationship.  The recognition that foster and adoptive parents may require professional assistance in dealing with extremely challenging behaviour is also very welcome.

One big question remains unaddressed.  To what extent is continuity of service provision required, not only throughout, but beyond childhood, and how could this be provided?  In an ideal world children can count on their natural parents for unconditional encouragement, assistance and protection into adulthood and for many years thereafter.  This kind of ongoing support is likely to be even more necessary for children already permanently damaged by their experiences.” 

Chris Bennett, Independent Research Psychologist 

 

“In recent years, there has been a constant flow of emerging evidence on the negative impact of adverse childhood experiences (ACEs) on emotional wellbeing, long term functioning and mental health outcomes. ACEs have been associated with many mental health symptoms and diagnostic categories. Depression, anxiety, self-harm, behavioural difficulties, and hearing voices, to name a few. New diagnostic categories such as complex post-traumatic stress disorder in the International Classification of Diseases (ICD11) is testament to this emerging evidence. 

 A young person who has experienced developmental trauma may have symptoms of many different mental health disorders. Enhanced understanding of the potential impact of ACEs across diagnoses has stimulated new perspectives on intervention. This shift is encouraging new treatments other than more traditional interventions. 

Dyadic Developmental Psychotherapy (DDP) is one such treatment. It is increasingly used by clinicians and accepted by service users, although it is yet to be backed by robust evidence. Care that is informed by the trauma that a young person has experienced, and therapy that focuses on addressing its impact on formation of attachment, must be properly tested.

Such research could give us a robust evidence base of effective treatments and open up new options for treatment. This would help children, young people and adults who have endured early adversities and trauma, and are affected by significant mental health difficulties.”

Pallab Majumder, Consultant Child and Adolescent Psychiatrist, Nottinghamshire Healthcare NHS Foundation Trust

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