The appointment of a task force on mental health is an initiative that is to be greatly welcomed. It is a recognition by the government of the importance of this vital area of our lives. The membership of The Task Force includes a representative range of voices each with their own expertise. These range from the scientific brilliance of Professor Mary Cannon to the charismatic advocacy of “Bressie" and many others besides.
The Task Force members has been given a big challenge and it will be interesting to see how they go about the work and what particular agendas they decide to cover. Much will depend on their terms of reference, their methods and their ambitions.
We might consider some of these agenda over the next few weeks and consider what the literature says about these mental health issues. Doubtless the Task Force knows what it needs to look at and we should let them get on with their work and wish them well. While we do let us consider for moment some of these key mental health agenda and consider them in anticipation.
Once such key agenda is Childhood. What is the relationship between our childhood and our adult mental health. The task force will already have the benefit of new data on the prevalence of mental health problems in our young population and also their lifestyle emerging from the “growing up in Ireland’ survey but what is to be said about the relationship between childhood and the developments of a mentally healthy adult life. For this data they must choose to look further a field.
The search for real answers to these questions rests on a very small number of long term studies. Two of these data-sets are worth highlighting. One of them is from the UK and the other from the USA. Their data tells us a great deal about the importance of childhood to the task of living life well.
First let’s look at the UK Birth Cohort Studies. These have enrolled more than 70,000 people from five generations starting in 1946 before the beginnings of the NHS. The research has become the longest running study of human development in the world. The results have directly influenced much government policy in health and education but also indirectly generated important data on childhood wellbeing.
The UK Birth Cohort data were reviewed recently in a new book entitled “The Life Project: The Extraordinary Story of our Lives”. Its author Helen Pearson shows how these data highlighted the effect of inequality and poverty on childhood and also its negative impact on the trajectory of adult lives. The results showed that children born into poverty and inequality were far more likely to struggle at school and much less likely to be employed in adult life. They were also far more likely to be in poor physical health.
On the other hand, the research showed that poverty in itself did not necessarily determine a bad outcome in adulthood. Many children thrived despite disadvantaged beginnings. In some of these children the influence of parental involvement was also a protective factor. For example children whose parents read to them when they were aged 5 years and who still showed an interest in their eduction when they were age 10 were significantly less likely to be in poverty at the age 30.
Clearly child poverty is a negative factor for childhood development and adult wellness. This makes intuitive sense and these data are consistent with all our experience. Sometimes poverty is in the foreground but other times it is in the background where it may be less apparent, but many would argue (and I would certainly agree) that poverty is the prevalent factor underlying most of our enduring health problems.
What about the influence of more specific trauma in childhood? What about the question of the long term effects of childhood abuse on the formation of adult wellbeing. An invaluable source of answers to these questions has come from the ACE studies in California, USA. These important studies are continuing at a large primary care centre in San Diego. The study methods include a look back at childhood experiences and a look forward to their progression from childhood to adulthood. The basic tool is a survey called the Adverse Events in Childhood (ACE) scale. It provides a score known as the ACE score and this can be used to correlate with other health and social data collected routinely by the practice. Over fifty scientific papers have resulted and the data is of profound significance for our understanding of childhoods impact on healthy living throughout the length of human life.
The ACE scale identifies ten types of childhood trauma. Each person is asked to recall their childhood and to answer ten questions about their life before the age of eighteen years. “Did you often experience any of the these five personal experiences physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect”. The next five ACE questions are related to the life of other members of the persons childhood family. “Did you have a parent or guardian who is alcoholic, a mother who is the victim of domestic violence, a family member in gaol, a family member diagnosed with a mental illness, or the loss of a parent through divorce, death or abandonment”.
Each factor is given a score of one and so a persons ACE score becomes very clear. For example an adult survivor of sexual abuse whose mother was the victim of domestic violence and whose father was an alcoholic would have an ACE score of 3. Any of us might try this scale for ourselves and calculate our own ACE score. This might be distressing exercise but it might be a useful one nonetheless. The question is what impact does the ACE score have on adult wellness.
The answer is a complex but compelling one. The ACE is a number used for correlation. It is nothing more and nothing less. It does not tell us anything about causes or cures. Nevertheless the ACE evidence is of a “strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several leading causes of death in adults. These causes include heart disease, cancer, chronic lung disease, fractures and liver disease, and these hazards are not secondary to smoking or alcohol use alone. Instead the researchers suggest they have found a real and independent correlation between childhood traumas and some of the major health problems seen in adult life.
So what about the relationship between adverse childhood experience and mental distress? The answer is that ACE is a risk factor for mental health difficulty. Estimates differ but the literature suggest that ACE events are three times more likely in those who have a major mental health problem such as schizophrenia or bipolar mood or borderline personality. Clearly ACE is a significant number but what does it really tell us?
Everyone agrees that ACE levels correlate with the emergence of serious physical and mental health problems in adulthood. The higher the ACE score the greater the likelihood of physical and mental health problems and even early death. The evidence supports the belief that childhood experience is important to our adult wellbeing. The question is whether childhood adversity is a determinant of adult ill health or just a factor.
The truth is that three quarters of adult mental health needs emerge before the age of 25 and this supports the conclusion that childhood is an important time for the development of our wellbeing. But other data suggest that a combination of factors influence our chances of remaining well. The ACE story is not the only story and it’s not simple. Nothing is. A number of important caveats need to be heard.
Childhood trauma and loss such as described by ACE events do not cause mental health problems or early death. Most people with ACE neither develop mental health difficulties nor die young. Those with high ACE scores who develop poor physical and mental health may be disadvantaged for many other reasons as well. We still do not fully understand the origins of poor health but we know this. The origins of illness are not linear. The successful pursuit of wellness is complicated by genetic effects and many other environmental factors. ACE is just one of these factors even though it appears to be an important one. Childhood adversity is a challenge but not a determinant of adult wellbeing.
The emphasis is rightly on reducing childhood adversity, so called ACE events, in the community in order to improve the overall population health. This is very understandable but even if all ACE events could be removed illness, mental distress and early death would still occur and in the majority of these people adversity would not have been a factor. The eradication of ACEs even if this was possible would not solve or prevent mental distress for many.
In any case the eradication of ACE events is not a realistic prospect. Meaningful health care proposals need to be based on facts not dreams. The ACE events are simply ten stress factors that emerged from this study in a large primary care setting. We are still struggling to reduce the volume of clinical factors contributing to ACE such as mental health problems and addiction. We must accept that violence and family breakdown and the experience of other loss in childhood is not going to go away. We are human. ACE events are not the only childhood traumas. Stress upon our youth will always exist to some degree.
Our health service responses cannot depend on wishing childhood adversity would just disappear. Prevention strategies should recognise the importance of ACE events but we also need to understand that childhood is a time that frequently includes a degree of stress and trauma. A meaningful plan for wellness cannot rest on primary prevention alone. Our childhood is valuable but it is not the only human value we possess. That is why we need to build resilience and still to provide real help for those in distress or difficulty. We must remember that being well is also about getting well again.
The Mental Health of Young People in Ireland: A report of the Psychiatric Epidemology Research across the Lifespan (PERL) Group. Authors: Cannon M, Coughlah H,Clarke M,Harley M&Kelleher 1 (2013) The Mental Health of Young People in Ireland: a report of the Psychiatric Epidemology Research across the Lifespan (PERL) Group Dublin: Royal College of Surgeons in Ireland
Growing up in Ireland. National longitudinal study of children. The findings of the qualitative study
Authors: Elaine Harris, Erika Doyle and Sheila Greene. Department of Children & Youth Affairs 2011.
The Life Project: The extraordinary story of our lives. Author: Helen Pearson. Published by Penguin Books
Relationship of Childhood Abuse and Household Dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study . Authors: Vincent J. Felitti, Robert F. Anda Dale Nordenberg et al. Am J Prev Med 1998;14 (4) 1998 American Journal of Preventive Medicine