Round Table Report English

Adverse Childhood Experiences (ACEs) Support Hub Round Table Events Discussion Themes

Introduction The Adverse Childhood Experiences (ACE) Support Hub have been working to raise awareness of Wales’ ACEs research since 2017. During that time we have listened to the many challenges and opportunities the research raises for people, particularly those working within public and third sector services. The feedback we receive is clearly telling us that people ‘get it’ and generally people are keen to know what they can do to make a difference. Some strong themes and potential obstacles, to creating an ACE informed nation, have emerged from the feedback and the Hub was keen to explore these themes further with selected representatives from across a range of sectors and organisations in Wales through a series of Round Table Events. The purpose of this exercise was to move-on from awareness by learning from positive and effective responses and draw on local and sector specific knowledge to influence the agenda moving forward.

Focus groups were held with parents and with young people ahead of the round table discussions to ensure that we consider their views too. The Round Table Events took place on: 10 April 2019 - Glyndwr University, Wrexham 9 May 2019 - Freedom Church, Cardiff 23 May 2019 – New Life Church, Llandrindod Wells The format for the event involved a presentation of the ACE Support Hub’s Core Messages slide set alongside findings from the parents and young people’s focus groups. Reflections on the feedback were invited from participants and any update on ACEs in their work, policy area etc.

The following questions were asked: What more needs to happen to enable ACE awareness/prevention and mitigation?

How can we best support each other to achieve ACE awareness/prevention and mitigation?

Key themes were presented and further discussed at a subsequent session for leaders and key influencers on 17th June, Cardiff & Vale College, Cardiff.

Discussion Themes

Key words and a common language The ACEs research, language of ACEs, has provided a shared (common) language across a range of public services / sectors. Universal awareness of the impact of ACEs across the life course is important, as is, a shared understanding around resilience.

There has been some resistance to the agenda. ACEs are nothing new – some professionals / practitioners feel undermined by the new “branding”.

Some professionals have been working with ACEs for years and welcome the new (common) language as it presents an opportunity to join-up, multi-agency / systems approach and opportunities for this to be sustainable. For others, they feel overwhelmed by a “new” agenda. We need to build on / develop work already happening and provide reassurance from public health that ACEs won’t be replaced by the “next new shiny thing”.

The Public Health Wales research provides the scientific rigour around what many professionals already knew. Has this resulted in criticism of the services they provide? Deficit around the scale, reach and depth of these services.

The focus has very much been on the ACEs, the negative experiences and the impact of these, rather than the solutions. Being ACE aware is just the start of a long journey that moves society towards a way of being together, being non-judgemental and more understanding. Trauma / ACEs is the context, but what is the point if healing is not the focus, therefore more strengths-based language is required.

In addition to resilience, kindness, compassion, understanding and awareness, relationships, connections, wellbeing, aspirations, selfregulation and coping are key words within the ACEs agenda.

Staff wellbeing and support is of equal importance to the wellbeing of and support offered/provided to service uses/clients/patients.

The ACEs agenda is not just about children it requires a life course approach. Clarity of language is important e.g., when we talk about ‘early help’ do we mean early in life or early in life of the problem?

Screening / ACE enquiry The common language provided by the ACEs agenda is enabling people to be “curious”; providing a framework for asking: “What’s happened to you? How has this affected you? What matters to you?”. For many it is the first time they have been asked and been listened to. That said, is it important that it is the right people who are asking. Who has the existing relationship? They should be asking the questions. Where there is rapport, with the time required and the permission. Permission to provide the right support; where there is not the permission this should be challenged. Cultural change within organisations is required.

In being curious and asking about ACEs we need to consider the risk of re-traumatising people by different professionals, different services asking the same question about their experiences again and again. A whole systems approach is required; how can the system be more personfocussed, must consider ‘customer-journeys’ with an infrastructure to support cross-agency working (e.g. sharing information).

It is important to remember that we don’t need to ask about ACEs to work in a trauma-informed way. We can be compassionate and curious and can facilitate universal resilience building without specifically asking about ACEs. There is a risk of over-professionalism with ACE enquiry / screening for ACEs – individuals don’t always need a diagnosis to get support. Professionals / services must consider what is it they need to know about the person to be able to meet their needs. What support / provision does the person want? How can services / systems be more person-focussed (the ‘what matters to the person?’).

We also risk over simplifying ACEs by creating them into a tick box exercise for ‘pathologising’ people. There is the danger of over simplification of the trauma experienced. One person’s experience is not the same as another person’s experience – consider context, wider adversity, resilience resources. Where there is a place for ACE enquiry / screening, we need to be specific about tools and when, where and how they should be used. More evidence is needed to support practical application of screening / ACE enquiry. Whilst there may be a benefit in ACE screening in that it can provide a process to gather information to inform the support being offered/provided, screening for ACEs should not create thresholds for services.

Context ACEs and other forms of trauma and adversity are often underlying factors for vulnerable people presenting with social, economic and health problems. We need to be more understanding of root causes of behaviours, symptoms and issues presented at services.

It is not just the ACE, the experience, the “thing” that is important, but also the context (personal and structural). We need to scale up the depth of ACEs for professionals to include social and economic adversity. The research / the language of ACEs can over-simplify what has happened to someone. People need their whole story validated. The list of (nine or eleven) ACEs does not consider all forms trauma and adversity. We need a more sophisticated narrative to include wider-adversity and consider context.

Policy context also needs to reflect this. We need cross-party working that goes beyond childhood trauma and takes into account the context - social and economic adversity and structural inequalities.

There is a risk that ACEs work focusses on the individual when actually the problem is a structural one. There is a risk that families are labelled as having ACEs without consideration to the wider adversity context.

(Double stigma of poverty and ACEs. Stigma of “free help”, stigma of asking for help, fear of being “intervened with”. Poverty may decrease access to resilience resources. On the other hand, areas that are more affluent might be considered as having less community cohesion.)

Community provision, community resilience – sits alongside mitigating difficulties associated with ACEs. Focus moves away from the family and into the community. Community connectedness is paramount.

Increased public awareness is needed; everyone needs to be aware of ACEs and to understand behaviours as survival / coping mechanisms. We need to ensure the branding and public communication is pitched right by hooking on a strengths-based campaign; power of relationships and relational approaches. There is the risk that services are not ready.

Structures and systems are not in place to support trauma-informed response. In addition, thresholds are an issue; we need to upskill those who can close the gaps.

Supporting the workforce ACE Awareness training across Wales is resulting in increased awareness and stimulating different thinking, helps to challenge assumptions, understanding the cause of the behaviour and symptoms, understanding the person, having better conversations.

Although a lot of awareness raising and training is taking place, more training is needed. ACEs are everyone’s business and we need everyone to be ACE Aware. There is the risk that ACE Awareness training provides a superficial understanding but overlooks certain aspects e.g. context, resilience resources and the “so what?”. Will lots of training being offered across Wales (from various providers including private consultants) what more can we do to quality assure the training and/or services who claim to be trauma-informed? Is there an endorsement role for the Hub? Staff wellbeing and support is a crucial part of being trauma-informed.

Supporting the workforce to be more trauma-informed it broader than ACE Awareness. The workforce should be equipped to develop their practice, to have good conversations to be relational in their approach. As we move from universal to more targeted work we need to facilitate expertise cascading out across all layers of the workforce with support offered to support change in practice e.g. through professional supervision. We need to think broader than training. Staff wellbeing needs to be an important part of the ACE-informed approach. Workforce consultation, supervision, reflective practice, reflective conversations, staff wellbeing support services, group supervision, peer support e.g. reflection and compassion networks for workers, are all useful elements of skills development, training and support.

ACE Awareness alone is not enough and we need to make sure we don’t rush in and apply what, seemingly, works in one area/sector/organisation and apply it elsewhere? One size does not fit all. A sector specific / sector-led approach, informed by evidence, is required. What does it mean to be trauma informed in your sector/organisation/service?

As the evidence base grows around effective ways to prevent, tackle and mitigate ACEs and local action is taken we need increased opportunities to learn together.

ACEs aren’t another intervention with funding attached for delivery, so how do we work differently? There is general will and passion from frontline staff to work a trauma-informed way but this needs to be supported by the organisation. An organisational approach is required leadership buy-in, brave leadership, culture of the organisation,

permission to work differently / permission to work in a more relational way, trauma-informed policies and procedures, support for the workforce.

Consideration to potential disconnect between being trauma-informed and what public services are measured on. For example compassion and enforcement; supporting people whilst also considering safety and structural requirements that we as professionals need to adhere too. The policy landscape needs to support organisations in this approach as well as facilitating the systems change required.

Leadership Commitment is needed from the top (leaders and commissioners); without this, there is little point in having ACE-aware people.

There needs to be real commitment, services ‘talk the talk’ but are still goal driven. Whilst it may be challenging in certain settings and sectors (e.g. to balance risk/enforcement with compassionate approaches or goal driven v’s relational), there needs to be a shift in language and approach from punitive language to compassionate language and relational approaches.

The workforce cannot change its practice unless policy and structure change.

Systems change The Welsh ACEs Study has provided local data for issues that, although are not new issues, are important cross-agenda issues that need to be addressed. In Wales, there are examples of organisations working together, collaboratively, towards preventing, tackling and mitigating ACEs. More is needed, on a local and national level, to join up and take collective action. Commissioning considerations and communication channels between agencies are important for progressing transformational change.

The system currently mitigates against the system change that is needed.

We currently work very much in silos perpetuated by strategy, policy and the way services are commissioned. The ACEs agenda needs to challenge this silo policy planning approach.

We need more universal provision and primary prevention services. If we had better investment in universally targeted programmes, in prevention, we should be able to prevent the escalation of problems. We need to challenge silo policy planning and commissioning and consider efficiency and value. If we join the dots across different services this will not mean more money, just better investment. For example, where services are doing the same things twice (not just around ACEs) we need the flexibility and permission to pool funding and governance to (prevent “empire building” / “protectiveness” and) support multi-agency working.

Cross-party government understanding of ACEs, support and leadership should be able to support the approach needed. As well as the role of Welsh Government, the challenge also needs to be led by Regional Partnership Boards (RPBs) and Public Service Boards (PSBs) (recognising that the infrastructure of PSBs and RPBs is still new and building relationships across partnerships is required to enabling risk taking).

Resilience A better and shared understanding of resilience is needed. The term ‘resilience’ is used too broadly (in strategy). More work needs to be done to describe and clarify what is meant by ‘resilience’ and how this applies in the reality of different contexts. For example: Young people having to be resilient when there are safeguarding concerns.

The answers are not necessary in services but in the community; community resilience should have an increased focus. We need a better understanding of community assets and a shared understanding of the evidence in relation to mitigating ACEs. We cannot just tell people to be more resilient. ACEs are not people’s fault. Lack of resilience is not weakness.

Culture shift There is a current disconnect between the outcomes needed to prevent, tackle and mitigate ACEs and the outcomes that services are generally measured on. “Softer” outcomes are the key things we need to be focussing on.

We need to have the permission to do things differently and to be (more) trauma-/ACE-informed and not be stifled by policy and processes.

The cultural shift needs includes community level response to behaviours/symptoms and the expectations of services to respond to behaviours/symptoms.

We also need to consider the ‘undiagnosed’ or those who do not meet thresholds (including thinking about the links to health harming behaviours); community response is key. There is a risk, otherwise, of diagnosis chasing – a potential “ACE Influence”.

We need to think about how services “do” prevention, mitigation and respond to ACEs. We need to think more broadly i.e. person-centred, whole-family approaches. Really, it doesn’t matter what the intervention is. The relationship matters. If the relationship doesn’t exist the intervention can’t work.

Thresholds for services and how services often exclude those whose needs we cannot fix (or cope with) must be considered. How do staff attitudes perpetuate this – does excluding people help staff feel better (or worse) than the way dealing with them makes staff feel. Training / organisational development approaches / service design needs to consider attachment and ACEs and what this means for staff.

What are the inhibitors for this required culture shift? Strategic language – trauma-informed needs to include language such as nurturing, parenting, resilience. Strategic buy-in and permission to work differently is needed. Culture change and bravery (there is currently a fear around not knowing what to do, the so what? Unlike with safeguarding where there is clarity around knowing what to do.

What are the implications around enforcement vs. compassion and the need to meet targets / what services are measured on?

What more needs to happen?

We need to be braver and work with whole systems to achieve transformational change

Develop the narrative Recognising that the conversation is more complex than the ACEs, we need a more sophisticated narrative (ACEs, ACEs across the life course, adverse community experiences, poverty, and wider adversity).

We need to describe the ‘so what?’ through a values, assets-based framework.

Workforce support Continue increasing ACE Awareness across public sector and voluntary sector workforce; ACEs are everyone’s business. Build on ACE Awareness and move towards ACE-informed people, policy and practice.

Training and additional support for the workforce to include:     

Informal learning opportunities with colleagues (with organisational cultural supporting this) Relationships and connection between professions/practitioners (shared understanding, shared learning, upskilling and support) Connection between experts/professions to practitioners providing upskilling and support e.g. clinical supervision, mentoring.

Workforce development approach e.g. consider the role of professional bodies and regulators to set the direction.

The language of ACE is the language of the research. Permission for the workforce to use their version of the language. Training to facilitate this translation into plain English / language that related best to the sector/service/organisation.

Quality assurance of resources / training packages etc., available. An evaluation of what works the best, for whom and in what context?

Organisational culture change - Permission to bring whole selves to work and practice through an ACE lens.

Share good practice through an ACEs Network.

We need to mitigate for empathic strain and consider workforce development issues (resources cuts, regulation limitations / push and pull – needs a top down approach organisational but also at a national level)

Braver leadership We need one “ACE voice” in Wales; a consistent approach (across Welsh Government, ACE Hub, EAT Programme) for services in Wales regardless of devolved or non-devolved. Messages and training needs to be the same with the flexibility to do it differently.   

Collective partnership, scrutiny and governance PI and targets vs. kindness / softer outcomes What we want to change as a result is kindness and compassion – how can this be measured?

PSB and RPBs as a vehicle for delivering ACEs prevention and mitigation.

Prevention, mitigation and response to ACEs to be included in all PSB Wellbeing Plans. Not just a high level (possibly ambiguous) priority/aim but specific thoroughly thought out actions / delivery mechanisms taking a systems thinking approach. We also need to apply an ACE lens to look across other activity in the plans ensuring that the determinants of health the social determinants of mental health are fully embedded within the WBFGA. We also need a consortium approach across Wales to think about how we can better support each other locally and nationally.

In terms of how services are commissioned and monitoring frameworks applied, we need to think about how to measure the relational outcomes needed. Particularly in statutory sector the fear of not following processes, meeting targets etc., may not result in the relational response needed.

Cross party leadership.

Guidance from Welsh Government – how we bring ACEs lens as a thread through specialist support services (MH, Drug and Alcohol, VAWDASV) at a local level.

Invest to save – invest in resources to save in the long term. We need long-term, span-generational, commitment.

There needs to be person-centred planning (Social services and wellbeing).

ACE-Aware communities ACE-aware training for communities – but how? Possibly not a one-sizefits-all approach. Included in this a bi-lingual offer is needed. How can we draw on connecting agendas? E.g. Urdd, Young Farmers.

Training for School Nurses and other “anchor” professional and organisations in the community need to be ACE aware / informed – leisure centres and sports facilities.

Community workers, community connectors – where do we use them?

Has the role, the ethos disappeared?

Social media campaign. Need to take risks with general messaging and be more confident. Look to other campaigns – ‘Time to Change’ – for inspiration.

Systems change within 3rd sector (National lottery fund) bid to include a consistent message WG, Hub, EAT Programme.

Signposting and access to support services through community connectors, social prescribers, system navigators.

Research More research on screening and ACE enquiry including considerations around the infrastructure of services in place. Position statement on screening/ACE enquiry is also needed.

More evidence on what works, for whom and in what context.

Cost benefits exercise.

Learning from evaluation.

How can we best support each other?

Systems thinking. We need to work collaboratively and collectively to build the answers. Look for solutions in the community. Commonality.

Culture of nurturing environments with all agencies on the same page.

Stop the silo working. We need to be joined-up in the way we work and this must be driven top-down as well as bottom-up. For example, silo working nationally (e.g. PHW/EAT Programme, F1000D, Welsh Government) leading then to problems / issue / narrow approaches locally or challenges within local partnerships.

Align services in order to avoid re-traumatising individuals/families through asking the same questions of them over again. Joined up approached through cohesiveness e.g. clearly defined roles. Alignment and joining-up will support a compassionate offer and one where there is choice e.g. choice over which professionals individuals engage with and the support they can access.

ACE Support Hub website should provide access to a range of resources.

Is there potential to present the website by sector.

Reflection and compassion network for the workforce. A conversation about the ways we support each other within the workforce and sharing staff support and wellbeing approaches and mechanisms for bringing our whole selves to work. We need to hold staff wellbeing at the heart of everything we do. Is there an opportunity to tap into Directors of OD for all Public Services and Staff Wellbeing departments?

Policy making and decision making through a whole-family approach / whole-person/ person-centred approach / ACE lens.

Workforce needs security and assurance about funding and commitment for prevention work. The workforce needs to feel valued.

Graduated response. Right help at the right time. Universal, early intervention, targeted services. (Self-referral. Not about signposting. It is where the relationship is where the intervention can sit.)