Written evidence submitted by the Greater Manchester Combined Authority (GMCA) and Greater Manchester Health and Social Care Partnership (GMCA & GM H&SCP) (EYI0047)
Further articles to support the evidence-base (including overseas experiences) for the link between adverse childhood experiences and long-term negative outcomes, and any gaps in that evidence base, as well as data on which specific adverse childhood experiences produce greatest adverse impact
Understanding and Responding to Adverse Childhood Experiences in the School Setting from USA but really clear and is helpful
Adverse Childhood Experiences and the Well-Being of Adolescents
Trauma Sensitive Schools
Reams of reports and resources that can be downloaded
https://traumasensitiveschools.org/research/
ACE & Trauma Informed Schools
The Impact of Adverse Childhood Experiences and Value of A Resilience Approach When. Working With Looked after Children http://www.virtualschool.lea.kent.sch.uk/perch/resources/markkerrvirtualschoolsjune2016.pdf
Using an Adverse Childhood Experiences tracker to inform targeted support in Glasgow
Routine Enquiry About Adversity in Childhood (REACh)
http://www.younglancashire.org.uk/webfm_send/1354
Adverse Childhood Experiences - Thinking Differently About Prevention (Wales)
Question four: the support and oversight of research into adverse childhood experiences and relevant interventions, including how research priorities are identified and funded, and the extent to which current interventions are reviewed and contribute to the evidence-base.
There is emerging evidence around the impact of ACE’s across a range of programmes and cohorts with multiple complex needs in Greater Manchester.
GM Health & Social Care Partnership – ITHRIVE
Greater Manchester’s Health & Social Care Partnership has recognised that exposure to Adverse Childhood Experiences have long term negative impacts on an individual’s life chances and health outcomes. The partnership has agreed to fund the establishment of a Greater Manchester ITHRIVE training and development team and hub that has been developed in partnership with Anna Freud Centre. Part of the delivery will be to develop training for the Children and young person’s workforce to deliver Routine Enquiry about Adversity in Childhood (REACh) as part of everyday conversations with children and young people.
Adverse childhood experiences (ACEs) are stressful experiences occurring in childhood that effect a child either directly (e.g. child abuse and neglect) or indirectly through the environment in which they live (e.g. exposure to domestic abuse, bereavement, parental mental illness, substance misuse or incarceration). Evidence has shown that ACEs impact neurological, Immunological and endocrine development, increasing stress on the body and individuals’ vulnerability to health‐harming behaviours, leading to increased risk of poor health outcomes across an individual’s life course.
Learning gained for an implementation of REACh across Blackburn with Darwen and research undertaken by John Moore’s University demonstrated that a REACH programme helped partner agencies - health, social care, education and criminal justice to become ‘ACE aware’ and to integrate this approach into longer term vision, strategies and training. It helped to identify gaps in provision for early help, for example in relation to bereavement and loss particularly for children & young people. Despite concerns that there would be an upsurge in demand for higher levels of intervention following disclosure this has not been the case.
It is planned to “weave” ACE and REACh/Trauma awareness and sensitivity into the i-THRIVE programme and to introduce training relating to Routine Enquiry into Childhood Experience (REACh) as part of whole workforce development.
THRIVE/REACh informed workforce transformation will be delivered via a multi-agency GM THRIVE training and development team and that will work under the umbrella of a GM training and development Hub. The Hub team will deliver the transformation model across all 10 LAs/CCGs. It is planned for team members and clinical leads to be linked with a locality and for team members to be able to “hot desk” within some agency settings.
Development work will be spread across clusters of LA/CCGs so that learning and progress from one setting can be transferred to another.
Salford Strengthening Families
The Strengthening Families project was developed in April 2012 by Salford City Council (SCC) Early Intervention and Prevention service when evidence showed in Salford that there were significant numbers of repeat pregnancies for parents who had had children previously removed from their care. Over a 5 year period there were 228 mothers involved in repeat care cases – affecting 644 children.
Over the same period 65% of all looked after children were from mothers who had had more than 1 child taken into care. Further investigation in Salford showed that this vulnerable group failed to access support or advice following the removal of a child. This often resulted in further pregnancies and left safeguarding concerns unresolved so that hundreds of mothers were stuck in a destructive cycle of pregnancies and care proceedings. Recent national research has shown that the gaps between care proceedings are short for these mothers. There was an average of 17 months between the first time a mum appears in court with an infant and the second time she appears in court with another infant. This provides a very short interval between pregnancies which gives mums very little time to turn their lives around (Broadhurst, K. et al, 2014, Capturing the scale and pattern of recurrent care proceedings:
Strengthening Families (SF) is an intensive specialist programme for pregnant women, pre 20 weeks gestation, who are at risk of their unborn child being removed from their care and parents who have already had children removed.
Profile of mothers in recurrent proceedings
Mothers who have appeared in recurrent care proceedings:
• Often became mothers at a far younger age compared to women in the general population, as well as those who appear in a single set of proceedings.
• Are more likely to have 4 or more children compared to the general population, where 2-child families are the most common.
• Majority of recurrent mothers are white/white British
• Had a range of issues as reported by the local authority. Service non-engagement featured as the most common key professional concern, a victim of domestic abuse, engaging in substance misuse and experiencing mental health issues
• Had been exposed to much higher levels of harm and adversity in childhood than what would be expected in the general population.
• Prevalence of abuse and neglect in their childhoods was high
• Some recurrent mothers had been looked after children
• A percentage of mothers had spent a period of time not living with their parents through an informal arrangement.
As you can see from the above profile there are a number of ACEs within this vulnerable group and the data provided from this cohort would be useful to evaluate to better understand future risk factors and possible interventions.
GM School Readiness
Early intervention to improve school readiness has the potential to improve a whole range of economic and social outcomes in later life, contributing to increased productivity and fiscal sustainability. By raising achievement at school, health outcomes through life, and ultimately creating wider opportunities for people to share in prosperity, improving school readiness will help to manage cost pressures in public services and put them on a sustainable fiscal footing.
Prevention and early intervention to improve outcomes and reduce cost later in life is a key priority for Greater Manchester. In GM it is acknowledged adverse childhood experiences can lead to long term costs and GM are convinced that ACEs can be reduced with the right early intervention. In the early years GM are committed to developing a consistent prevention and antenatal offer alongside the development of a high needs pathway and perinatal and infant mental health pathway which will start in pregnancy offering the earliest opportunity to prevent future generations of ACEs.
Integrated substance misuse treatment and recovery
Professionals working within substance misuse treatment service have found that many people who are on the road to recovery, and may otherwise be able to complete their treatment, aren’t unable to come of substitute medications completely because of trauma. At the point when they are starting to become more lucid traumatic events from the past are likely to resurface. Often it is these traumatic events that led them to start using drugs as a coping mechanism – in their words using illicit drugs to self-medicate.
Specifications for integrated substance misuse treatment and recovery service in Greater Manchester now include reference to the need for deliver specialist psychological interventions addressing the issue of trauma (including adverse childhood experiences) within the treatment system, using appropriately trained specialists.
Greater Manchester Women Offenders
Greater Manchester operates the Whole System Approach for Women Offenders to improve outcomes and reduce reoffending for women in contact with the Criminal Justice System. It is the only such whole system approach in the country and is held as an exemplar of good practice by the Ministry of Justice and the National Advisory Board on Female Offenders.
Due to the processes that have been set up as part of the Whole System Approach, GM are now able to build a relatively comprehensive picture of need, which in the medium to long term, should help GM make the case for wider public service reform. In Greater Manchester, we know that:
• 73% of women entering the Criminal Justice System have a mental health/wellbeing issue,
• 47% have a substance misuse issue,
• 42% have experienced Domestic Abuse and
• 24% a physical health issue.
• In addition 89% have multiple needs and 47% have needs in at least 5 of 12 re-offending pathways.
This data linked to other academic evidence leads us to believe that a high percentage of these women will have suffered 4 or more ACE’s in childhood.
Many women offenders also have children and the effect of their offending on their families is often significant, which places women offenders at the heart of many strands of Public Service Reform, in particular, complex dependency. This adds to the belief that utilising the REACh intervention with this cohort of women will not only allow them to improve their ability to deal with the situation they find themselves in but also to help tackle intergenerational trauma and the subsequent potentially poor outcomes for those children.
GMCA are proposing to use the REACh approach as a proof of concept to engage this cohort of women and to measure potential outcomes for the women and their families to establish what extent this intervention improves their life chances. The evaluation would also model the impact on services and the potential cost benefit of adopting this approach at a larger scale. This will be delivered by training professionals and volunteers who work with women offenders from the network of local women centres already in place across Greater Manchester.
Question five: mechanisms for bringing together the collection, communication, application and review of evidence to ensure interventions are evidence-based.
Extensive evaluation for some of our large scale programmes in Greater Manchester such as the troubled families programme is helping to build a strong evidence base and improve our understanding of people with complex needs. It includes a detailed view of presenting issues and evidence of impact of particular interventions and approaches that is subsequently shared with operational leads across the region.
Question one: the evidence-base (including overseas experiences) for the link between adverse childhood experiences and long-term negative outcomes, and any gaps in that evidence base, as well as data on which specific adverse childhood experiences produce greatest adverse impact
The Adverse Childhood Experiences (ACE) study grew out of innumerable counterintuitive observations that were made in the course of operating a major obesity programme. Being forced by patients first to recognise the frequency of childhood sexual abuse, then of major household dysfunction during the developmental years, the ACE Study represented the desire to determine in a general population the prevalence and long-term significance of these problems that we had not before considered in adult medicine.
Compared with people with no ACEs those with a score of 4 or more were found: 2 x as likely to binge drinking and have a poor diet; 3 x more likely to be a current smoker; 5 x more likely to have had sex under the age of 16 years; 6 x more likely to have had/caused an unplanned pregnancy; 7 x more likely to be involved in violence in the last year; and, 11 x more likely to have used drugs and/or been in prison.
Waiting to be told doesn’t work. ACE are best framed in the context of routine enquiry. 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
References
Welsh Assembly animation on ACE
Password for Video link is Wednesday
Tedtalk on ACE
Scottish Public Health Network (ScotPHN) 'Polishing the Diamonds' Addressing Adverse Childhood Experiences in Scotland Sarah Couper and Phil Mackie
May 2016
2015 Public Health Wales NHS Trust – Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population
Alaggia, R. (2004). Many ways of telling: Expanding conceptualizations of child sexual abuse disclosure. Child abuse & neglect, 28(11), pp.1213-1227.
Allen, J.G. and Fonagy, P. eds. (2006). The handbook of mentalization-based treatment. John Wiley & Sons.
Bellis, M.A., Lowey, H., Leckenby, N., Hughes, K. and Harrison, D. (2013). Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health, 36(1), pp.81-91.
Bellis, M.A., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014). National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC medicine, 12(1), p.72.
Centre for Disease Control. (2017). Adverse Childhood Experiences (ACEs). [online] Available at: https://www.cdc.gov/violenceprevention/acestudy/ [Accessed 5 Feb. 2017].
Department of Health. (2015) The Future in MInd. Department of Health
Department of Health. (2015) Tackling Child Sexual Exploitation. Department of Health.
Dorahy, M.J. and Clearwater, K., 2012. Shame and guilt in men exposed to childhood sexual abuse: A qualitative investigation. Journal of child sexual abuse, 21(2), pp.155-175.
Filetti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M. and Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), pp.245-258.
Frattaroli, J. (2006). Experimental disclosure and its moderators: a meta-analysis. Psychological bulletin, 132(6), p.823.
Glover, D.A., Loeb, T.B., Carmona, J.V., Sciolla, A., Zhang, M., Myers, H.F. and Wyatt, G.E. (2010). Childhood sexual abuse severity and disclosure predict posttraumatic stress symptoms and biomarkers in ethnic minority women. Journal of Trauma & Dissociation, 11(2), pp.152-173.
Marriott, B.R., Lewis, C.C. and Gobin, R.L. (2016). Disclosing traumatic experiences: Correlates, context, and consequences. Psychological trauma: theory, research, practice, and policy, 8(2), p.141.
Pearce, J., Murray, C., Larkin, W., and Simpson-Adkins, G. Asking about Childhood Adversity and Trauma: Experiences of professionals trained to routinely enquire about child adversity. Manuscript submitted for publication
Read, J., Hammersley, P. and Rudegeair, T. (2007). Why, when and how to ask about childhood abuse. Advances in Psychiatric Treatment, 13(2), pp.101-110.
Read, J., McGregor, K., Coggan, C. and Thomas, D.R. (2006). Mental health services and sexual abuse: the need for staff training. Journal of trauma & dissociation, 7(1), pp.33-50.
Real Life Research (2015). An Evaluation of REACh: Routine enquiry into adversity in childhood. Independent evaluation of work commissioned by Blackburn local authority public health team.
Larkin, W. & Read, J (2009) Childhood trauma and psychosis: Evidence, pathways and implications. Journal of Post Graduate Medicine, 54, 287-293.
Simpson-Adkins, G. J., and Daiches, A. (in press). Exploring the Impact of Enquiring About the Adverse Childhood Experiences of Parents. Manuscript submitted for publication
Tedeschi, R.G. and Calhoun, L.G. (2004). "Posttraumatic growth: Conceptual foundations and empirical evidence". Psychological inquiry, 15(1), pp.1-18.
Tener, D. and Murphy, S.B. (2015). Adult disclosure of child sexual abuse: A literature review. Trauma, Violence, & Abuse, 16(4), pp.391-400.
Young, M., Read, J., Barker-Collo, S. and Harrison, R. (2001). Evaluating and overcoming barriers to taking abuse histories. Professional Psychology: Research and Practice, 32(4), p.407.
Question two: the quality of the existing evidence-base for specific early-years interventions that aim to address adverse childhood experiences and minimise their effects in later life
References
The first thousand days: an evidence paper September 2017
http://apo.org.au/system/files/108431/apo-nid108431-436631.pdf
The Greater Manchester Assertive Outreach Model, including Baby Express
see http://archive.c4eo.org.uk/themes/earlyyears/vlpdetails.aspx?lpeid=471
Early Intervention: The Next Steps
Independent Report to HM Government by Graham Allen MP 2011
Disadvantage, Behaviour and Cognitive Outcomes: Longitudinal Analysis from Age 5 to 16
Early Intervention Foundation, 2017
20-
Foundation Foundations For Life
http://www.eif.org.uk/publication/foundations-for-life-what-works-to-support-parent-child-interaction-in-the-early-years/-child-interaction-in-the-early-years/
Early Intervention, 2016
Question three: the extent to which local and national government policies for early-years intervention reflect that evidence-base, and the challenges involved in disseminating, accessing and using the latest evidence, as well as the opportunities for intervention suggested by the evidence but not currently being implemented.
The early years system creates multiple points to collect data on different systems by different staff funded by public money e.g. GP, midwife, health visitor, children’s centres and day care providers even at the universal entry points. This mixed measure of early years implementation can make data collection on evidence from a child’s and primary care giver’s viewpoint hard to determine. This is a systemic issue not dissimilar to those services offered to people towards the end of their life, but in this instance we now have health and social integration.
The ASQ3 Social Emotional measure is the best evidenced measure to assess the progression of child development from two months to five years. As it is using a measuring score an amalgam score could be created linking this to the foundation stage assessment, assuming the multitude of people working in pregnancy and early years use the same assessment tool. At present, the Department of Health bought only the UK paper license for ASQ3 in its broader purchase of the Family Nurse Partnership from Brooks Publishing in the USA. This makes the fast paced sharing of this evidence and tracking very cumbersome as it’s all on paper. Jon Rousse Chief Accountable Officer for H&SC Partnership for GMCA has written to the Rt Hon Jeremy Hunt MP asking him to request the online version of ASQ3. The online system will enable the tracking and collection of live data for service planning.
If ASQ3 was prioritised as a central government purchase and rolled out nationally as policy advice on best practice it would enable a common national tracking assessment of child development 0-5 yrs. At present we only use a measure in the second term of foundation year at school. When you look at human potential and adversity is crystal clear that gestation to aged 2 years are the most critical years and yet we have no measure of progress tracking those time frames from a child development viewpoint. Whatever the model of practice and other suite of evidence based/supported tools were being used in composition in any number of localities would at least have a common tracking measure to baseline the critical early years trends, investment and impacts.
GMCA produced an Investable Proposition for early years including pay back periods and which Government Departments benefitted the most. The early years system breaks even at aged 7 years which does not fit into any election cycle. The Department which seeks to benefit the most from a good, evidenced early years system is DWP when the cohorts mature to 16 yrs. Yet the DWP is not an investor in the early years system and the national narrative around early years is not about inclusive growth and long term economic strategies. It needs to be and guarded as protected public services.
Question four: the support and oversight of research into adverse childhood experiences and relevant interventions, including how research priorities are identified and funded, and the extent to which current interventions are reviewed and contribute to the evidence-base.
We are using some of our own money to invest in Adverse Childhood Experiences (ACE) in the context of trauma informed practice in one ward of the city. All public and VCS services whether provider or commissioned who provide operational frontline delivery in one ward will be trained, coached and developed to offer a trauma informed approach to engaging with current and future service users/people with lived experience. The organisations who have been engaged and want to take part in this new, integrated model of workforce reform include Integrated Neighbourhood Teams, police, GPs, youth services, VCS, Health & Social, Early Help, fire and rescue, mental health services, domestic violence and abuse services, early years services, health visiting, schools and substance misuse services.
The project is looking to test whether having a trauma informed workforce at place level (not particular organisations) makes a difference to the workforce capacity to engage on a deeper level with service users/people with lived experience they are already working with. Having had a deeper level of engagement and understanding of the root causes of behaviours rather than “treating” presenting behaviours does it make the current intervention offer work better? Will it allow for deeper integrative workforce capacity at place level with less of a focus on managing inter-professional identity in teams and more about a common conversation tool to engage? Will it also evidence commissioning gaps to help inform future commissioning at place level?
The Our Manchester priorities the project will contribute to include a strong sense of citizenship for the City with a true sense of Pride understood by residents and staff that the chosen ward is a fantastic place to live, study and work. Trauma informed work has strong evidence that it can help to improve the health and wellbeing of children and adults. This will enable us to work as a true partnership at place level on the wider determinants of health. If we work in partnership with families at place level. It is within our gift to create an increase in the number of apprenticeships for the people of in this ward with pathways to graduate level study in health and social care. This anchors firmly into our delivery of the Family Poverty Strategy and our emerging narrative on Inclusive Growth. If the staff are focused on one common conversation tool at place level to improve standards of frontline practice this should lead to an increase in workforce productivity. If this learning proves relevant to be scaleable it could live wire transformational change in workforce practice on the integration of reform.
There are two sets of people who are assumed to benefit from the project: service users/people with lived experience who are currently engaged in services are able to engage and move forwards with their lives once intervention has ended; and, frontline staff who will have far greater insight into how traumatic childhood experiences interfere with child and then adult development and this will deepen their level of practice across a place and not just one employer organisation.
There is compelling evidence there is a current problem and opportunity that the project is looking to address. The ward we have chosen has a fairly static population compared to other areas of the City as demonstrated annually in our State of The City Reports. Additionally, service heads in the ward have told us that any thematic issue could be chosen e.g. child sexual exploitation, ASB, school attendance, worklessness. The issues themselves are therefore not the issue, rather the complexity of multiple traumas which extends beyond understanding of the “toxic trio” a common feature into reviews of child deaths. The Adverse Childhood Experiences (ACE) work on routine enquiry offers the opportunity of a different engagement conversations that acknowledges that what happens to a person when they are young is not their fault and that unresolved harm they experienced may be somehow related to current behaviours. If people feel respected, listened to and engaged they are far more open to the idea of different strategies moving forwards. This allows frontline staff to have far more of a blank mind approach leading to better de-escalation practice with service users/people with lived experience.
Frontline practice will be able to practically demonstrate that they work together and trust each other by co-designing the implementation plan for training, respecting one another’s ideas and innovations, training together, being supervised together and share learning and development in a place.
Staff will able to take pride in not having a model of practice that unwittingly blames either an adult (if the trauma is past) or child (if trauma is current) for the abuse and harm they have experienced as children. It was not their fault. They were/are children and had little choice and control. There is a common understanding that all services in the place understand this and appreciate how current behaviours and strategies can be linked to unresolved childhood trauma. They can take pride in offering a more insightful level of practice and new strategies to coach service users/people with lived experience in new strategies that they may now be open to which they would not engage with before.
Frontline staff will own it by co-designing the whole implementation plan and training package before any training starts so we co-produce owning the implementation at place level. Service users/people with lived experience will also be given the opportunity to own not being blamed for being victims/survivors of childhood traumas and given a great level of insight and therefore agency that they have a gift to change their thinking and therefore their actions and related outcomes.
By investing in a trauma informed approach at place level, integrating all workforces, the Manchester will be able to demonstrate that it is not afraid to try new things. Robust evaluation will be put in place to identify key learning and what is scaleable to help inform future workforce transformation.
Manchester does have competent experience in testing routine enquiry via the IRIS GP whole practice training tool funded by Manchester Health and Care Commissioning for all practices in the City to screen for domestic violence and abuse. This approach is aimed at people who experience abuse from either a current partner, an ex-partner, or family members and refers them into specialist support services. Evaluation of IRIS shows that routine enquiry encourages safe disclosures before an individual reaches crisis point. The implementation learning is transferable to our ward ACE work.
By design, the implementation is being co-designed with frontline practitioners first and foremost; they are the experts on place; they understand what helps and what stops them from doing their best and what support they need in place to make a design idea on paper actually happen in practice. They are our key experts to bring about change. We recognised the frontline are the business; not the back office functions. They have the right experience, insight and skills to help us design to implement. The implementation system is being driven by the frontline and not the other way around which gives the ideas better traction to landing in every day practice.
There are no treatment fidelity/model fidelity on how best to implement ACE and as such, no NICE guidelines on what makes a good enough ACE model (unlike other behavioural science models such as evidence based parenting programme guidelines see https://www.nice.org.uk/guidance/cg158.
Question five: mechanisms for bringing together the collection, communication, application and review of evidence to ensure interventions are evidence-based.
The national What Works Centres the Early Intervention Foundation and Education Endowment Fund already provide a great deal of comprehensive advise on how to collect, apply and review interventions to ensure they are evidence based.
Manchester has implemented a great number of evidence based interventions over the last two decades with success including Incredible Years, Multi-systemic Therapy, Family Nurse Partnership, Triple P, Families First, Family Intervention Project, Solihull Approach, NBAS and NBO, Care Index, Video Interactive Guidance, Strengthening Families Strengthening Communities and Strengthening Families 0-14 years programme, Signs of Safety and Safe and Together to cite some of them. We have also learnt from innovations from Children’s Fund.
The selection of evidence based interventions is relatively easy to do. Matching needs, cohorts and undertaking cost benefit analysis is doable. The challenge is sustaining non-statutory services as times of reducing budgets coupled with rising demands for statutory interventions determined often by wider issues that the quality of the early intervention offer e.g. poverty, quality of housing stock etc.
There is a golden opportunity via the opportunity of the apprenticeship levy to create mainstream workforce development and in social value in commissions to create new apprenticeship national standards which include the suites of evidence based interventions as the standards, thereby making the training and supervision mainstream budget provision.
December 2017