Last week two important reports hit our desks and they are closely linked. The first is Sir Michael Marmot’s Review ‘Health Equity in England 10 Years On’ which tells a sorry tale about the increase in child poverty which has risen to over 4 million children affected and a decline in healthy life expectancy and good health years in terms of gender, ethnicity and geography. It shows that health is closely linked to economics and social policy. The second is a report by the Early Intervention Foundation (EiF) focusing on Adverse Childhood Experiences (ACEs) and the impact on both mental health and physical health across the life span.
The EiF report states that childhood experiences of discrimination have been found to increase the risk of adult mental health problems by over 200%. Findings in a recent US survey found that family income was more strongly associated with poor physical health in adulthood than all of the ACE categories with the exception of having a family member with a mental health problem. It is a welcome contribution to the debate around the impact of early adversity in all its forms, providing an in-depth look at how we can use this framework to help us to better understand risks and what makes a positive difference, protective experiences as well as risks.
Both studies show that early experiences have a profound influence on how we live our lives and what enables every child to have the best start in life. The Marmot study reinforces the fact that ACEs are more frequent lower down the social hierarchy and the social determinants of health are as important in terms of good health outcomes as general healthcare provision. Our life circumstances and the burden of adversity matter more than anything else. There is huge inequality which is partly to do with austerity measures over the last ten years and partly to do with social policy or the lack of a coherent policy which addresses social inequality.
Social processes which link ACEs to negative health outcomes include :
- Abusive family interactions which are learnt and repeated across generations
- Exposure to different forms of abuse by both peers and adults in a child’s environment which increases their vulnerability to victimisation
- Lack of trusted adults and positive relationships which could increase the child’s resilience and sense of self-worth
All of these processes are capable of change and show that poor health is preventable if we reduce the stress on families and address the social mechanisms that create ACEs.
When the ACE study was first published the authors concluded that comprehensive strategies involving universal and targeted interventions were necessary to prevent ACEs. These strategies included :
- Intensive home visiting for vulnerable families
- School-based programmes aimed at preventing health-harming behaviours
- Targeted psychotherapy to address specific difficulties
- Treatments that aim to help children and parents to cope with trauma
The EiF report shows that we have invested in routine ACE screening and we have begun to develop initiatives around trauma-informed care but it asks us to consider if ACE screening is acceptable or helpful and questions how it is done and what training is given to professionals to ensure that the practice is sensitive and not re-traumatising.
We should aim to decrease stress and increase resilience through building greater trust between vulnerable families and the professionals who are there to support them. We know that there is often fear and distrust between families and services which means that they do not seek or welcome help.
The 2010 Marmot Review identified a number of actions necessary to make a difference :
- Give every child the best start in life
- Enable all children and young people to maximise their capabilities and have control over their lives
- Strengthen the role and impact of ill-health prevention
If we are to make progress in reducing health inequality we need a concerted effort across all services and a national strategy to improve the life chances of the next generation. We need to shift the balance towards prevention and early intervention.