Responding to adverse childhood experiences: A child and adolescent psychiatrist’s perspective

In this article (Hiscock, 2018), the author critiques the quality of responses to adverse childhood experiences (ACES) in Australia – the dubious nature of some interventions, lack of training of practitioners and recommends interventions to decrease vulnerability and increase resilience in children.

The focus in Hiscock’s article is on mental health at all levels, and paediatricians she says are ‘in an ideal situation to act on ACES’ adding that the bulk (60%) of an Australian general paediatrician’s caseload consists of children with developmental problems, including anxiety, attention deficit and behaviour problems. Child psychiatrists have received extensive training to diagnose and manage these mental health conditions, beyond the pursuit of their neurobiological cause. They are also required to demonstrate participation in rather extensive continuing education. Hiscock cites the lack of training at a practitioner level, with which I totally agree – all health practitioners who work with the psychological problems of children must be required to have had an appropriate clinical training in child and family mental health and be subject to maintenance of continuing education standards.

This raises the question of competence. Although it defies definition, competence may be described as possessing three major components: knowledge, skill and diligence which aims to reduce the likelihood of harm, increases the potential to be of help and is the most obvious ethical obligation of the practitioner. Similarly, where there is psychological treatment, there is need for supervision of this treatment as it enhances both knowledge and skill and monitors effective practice. Both are seriously lacking across the mental health sector. What good can come of providing services that do not have the potential to succeed?

Dr Hiscock not only advocates for integrated services but also says that paediatricians cannot accomplish this on their own.

Is there any role for child psychiatrists? Is it not time to make appropriate use of the child psychiatrist and clinical child psychologist sooner, rather than later, in a wider variety of circumstances, not just in instances of violence, psychosis and suicide? Early intervention by appropriately trained clinicians, particularly in children with several ACES, is essential, given that the incidence of dissociation in a number of such children may be overlooked, and for which the child psychiatrist is in an eminent position to play a consultative/tertiary, quaternary role. Better outcomes would result than what are currently being achieved.

The role of poverty is emphasised in this article, whereas exposure to ACES is common across the world, with a similar prevalence in high-income (38%), high-middle-income (39%) and in low- and lower-middle-income (39%) countries (Kessler et al., 2010). I propose that a common factor is at play, which could account for prevalence of ACES in both rich and poor families – failure in prenatal and infant – caregiver attachment, a bio-psycho-social process which has the potential to increase children’s susceptibility to emotional, physical or sexual abuse and neglect, whereas healthy attachment contributes to resilience (Sroufe et al., 2005). By infancy, risk factors for adult mental illness are highly prevalent, with 51.7% of infants having multiple risks that can be modified (Guy et al., 2016). Obstetricians, neo-natal paediatricians and clinical nurses, clinical psychologists and child psychiatrists are excellently placed to intervene with an attachment framework and an emphasis on the mother–infant relationship. Similarly, education of early educators and other human services providers will contribute to a knowledgeable workforce that can detect problems, manage them under supervision and refer difficult presentations early. Lack of space precludes adequate comments on the tools and assessment scales suggested in this article.

The importance of trauma-informed, that is, a comprehensive multilevel approach that shifts the way organisations view and approach trauma cannot be overstated, as failure to be aware of a child’s traumatic experiences may lead to re-traumatization and failure to provide appropriate referral. I agree that the prevention of early adversity has never been clearer. Identification by early childhood educators, and other early childhood practitioners, of at-risk children can lead to further screening and treatment embedded in already existing multidisciplinary child and family health systems, which must be staffed with properly trained and supervised clinicians, rather than the development of new single-site or virtual services.