Dr John Marshall: Jonah Lomu and Salvador give the lie to ACE trauma theories

Scotland's Cammy Murray takes on Jonah Lomu , who from an early age was exposed to gang violence. Picture: Ian Rutherford

They all suffered considerable Adverse Childhood Experiences, or ACEs but their ACEs scars also drove them on to excel. ACE’s includes suffering physical beatings, sexual abuse, neglect, parental separation or divorce, an imprisoned parent, witnessing domestic violence, or living with a parent who had a drinking, drug or mental health problem.

Bullying by peers, poor quality housing, poverty and death of a parent don’t figure in the original conception of ACEs despite the substantial risk of mental health problems conferred to children from the pain of early parental loss, deprivation and mistreatment from peers. Children in socioeconomic disadvantage are more likely to experience multiple ACEs. ACEs are touted as a major causal factor for many bad life outcomes.

In Scotland ACEs and their associated psychological problems, especially trauma, is the dominant discourse. ACEs prevention enthusiasts use dramatic metaphors like “toxic stress” disturbing brain development, causing brain system “damage” or the “body remembering”, but the mind forgetting, embodied distress.

Although the science is yet to prove the causal mechanisms happening between ACEs experiences and poor health, there is another side to the ACEs story.

Vincent J Felitti, Physician and Head of Preventive medicine, from 1995 to 1997, in a large private clinic in San Diego, for white middle-class patients, found that when it comes to ACEs time does not often heal and people just don’t “get over it”. The real ACEs breakthrough is the idea that we are wrongly focused far downstream in health, to the consequences of ACEs.

The chronic stress of ACEs “gets under the skin” and changes human developmental processes, leading to ill health. ACEs are correlated with future mental health and physical health problems. Some ACEs purists state that those who grow up in violent homes are “scarred for life” developing substance abuse and crippling mental health issues and they may even grow up to become violent themselves, keeping the ACEs cycle going. Many ACEs backers work with people who have mental health problems, linked to ACEs or are traumatised ACEs survivors themselves with the courage to write about their experiences.

But those who grow, function or thrive in the face of sometimes considerable trauma are less newsworthy.

From depression, alcohol and drug problems to obesity, cardiovascular disease, respiratory problems and cancer, ACEs are in the frame. From a science perspective I was always taught that when one thing causes everything else, it’s time to be wary. As many readers know, a relationship, or correlation, between two things – ACEs and suicide, for example – does not mean one causes the other.

Tucked away in ACEs research, often toward the end of studies, is the all too common phrase that their studies are not able to discern “causal inference”, meaning we don’t really know if ACEs caused the bad outcome in the study, or, if it does, we don’t know by how much, or even how. It’s exciting if we feel x causes y as our mind seeks out simple connections, then runs with them.

Scotland has the laudable aim of becoming an ACE-aware nation, but networks of causal factors are hard to disentangle and very difficult to study.

To infer causal factors researchers will need to consider a range of environmental issues beyond parenting and family systems, such as the role of poverty or pollution, not to mention poly-genetic and epigenetic factors. Nevertheless, we are vaulting ahead without the causal research to back up the primacy of the negative causal role of ACEs or about how ACEs interact with other factors.

But maybe like the absence of research on the effectiveness of parachutes shows, skydivers die without them, we don’t need to do the research, a world with fewer or no ACEs would be a better place to thrive in, or is this a utopian vision where the stuff of life never happens?

Many readers will know or become more aware that they also have a background of ACEs, some are unaffected, pushing forward with successful lives, some are bruised yet function well, others are shattered, despite comparable ACE experience. Professionals are highly aware of ACEs.

I recall being told authoritatively by a health visitor that ACEs always disrupt attachment, if that happens under 3 years then “that’s it for life”.

The dangers of ACEs are in writing children off.

ACEs don’t take account of subtlety, a parent with short-lived depression versus a parent with chronic psychosis both count as parent with mental health issues, in ACEs research. When we simplify problems and over-focus on one cause and put all our eggs in one ACEs basket we fail to account for human complexity.

It is well known that there are problems relying on people’s memory of ACEs (this is how ACEs are identified in research). Adults who are suffering mental health problems have memory biases and amplify the recall of adversity in childhood. The issues are complex for researchers; if they discover ACEs ongoing with a child they have to ethically intervene.

The ideal research to disentangle causal pathways has not been carried out. However, adverse experiences are processed via relationships with parents and family, maybe that’s what really counts for life, compared to whether bad things happen.

ACEs may be associated with disturbance, but that isn’t the same as psychological trauma. Yet it’s really hard to get trauma symptoms.

Defying all expectations, post 9/11, only 0.6% of Manhattan residents close to ground zero suffered PTSD after 6 months, and with symptoms rapidly declining for that tiny group. Some people fold in the face of ACEs, some survive, many reframe ACEs to propel themselves forward in life with grit and determination. The reason for this is resilience. Under extreme or chronic adversity many of us who have experienced ACEs are forced to grow.

Recent studies on performing artists (dancers and singers, for example) show that those with high numbers of ACEs are more creative.

Artists with more ACEs have a greater sense of pleasure, power, meaning, and purpose during their imaginative endeavours.

Unresolved mourning and higher ACEs have been found among actors compared with a control group.

Anxiety and vulnerability are closely linked to the creative process. Another study has found super performing athletes who were Olympians had more ACEs than non-Olympic athletes. In another study athletes with higher numbers of negative life events performed better under a test of performance and pressure.

The researchers went as far to say that “prior brushes with adversity, should be considered when identifying athletes who are likely to excel during stressful competition”. The idea that talent needs trauma perhaps overstates the research evidence, which is mixed, but the concept of post-traumatic growth and creativity might be relevant for many on ACEs journeys. The danger of ACEs becoming synonymous with trauma and negative life outcomes could eclipse stories of resilience and growth.

The prescription given to reduce ACEs and concomitant trauma, attachment problems and in fact most of life problems comes down to loving each other, relationships, attachments and more love. If we just love everyone, our children, each other and place relationships above all else, ACEs will melt away like the fruits of a blissful commune in a Californian sunset. I’d like that, but in the real world flat-out parents have to foster their kids emotional and cognitive skills, be aware of their own and their child’s emotions, validate their emotions, assist with labelling them, and use emotions as opportunities for intimacy and instruction. At the same time parents have to impose firm but fair rules and limits consistently, contain stress and overbearing emotions, multi-task, develop and maintain household routines and predictability and, of course, provide that all important love – all while making ends meet through work.

Making tough parenting decisions with the limited resources you have, being present, providing security and stability show that love is not enough to be a good parent. When it comes to experiencing trauma, from ACEs, love and relationships are heavily promoted, even that it’s only about relationships. Often relationships are an ominous prospect for people with ACEs and complex trauma. Developing therapeutic relationships is important in psychotherapy but simply taking this “relationship” approach alone is not likely to lead to clinical change. Saying that it’s only about relationships is a psychotherapeutic apostasy of our modern age. Asserting sagely that adversity is bad for you is obvious, it is pseudo profundity, akin to pronouncing that oxygen keeps us alive. What’s more essential, whilst trying to reduce ACEs, is to work out what makes some people collapse in the face of childhood adversity and others grow. Once we work out these answers scientifically, we can make more informed decisions about targeting our resources where they are most likely to be needed.

Dr John Marshall is a Consultant Forensic & Clinical Psychologist.