Setting the scene: definitions of ACE, psychosocial outcomes and protective factors

Negative outcomes after childhood adversity are not inevitable; individuals who experience ACEs can still flourish later in life despite experiencing significant early adversity. Protective factors operate to interfere with or disrupt the realisation of developmental trajectories between risk factors, such as ACEs, and poor health and social outcomes. Theories of resilience have evolved from being perceived as a stable trait of relative invulnerability to stressors, to that of a dynamic process of interaction between the individual and their environment.^{Reference Vella and Pai6} This process is partly influenced by genetic predispositions of temperament and stress physiology, and social factors such as early attachment and social learning. ‘Positive adaptation’ in the face of adversity can be understood as the presence of a positive outcome (e.g. financial security) or the absence of a negative outcome (e.g. absence of psychopathology) after exposure to adversity.

What protective factors show promise?

The systematic review and narrative synthesis in BJPsych Open by Buchanan et al^{Reference Buchanan, Walker, Boden, Mansoor and Newton-Howes7} summarises the current evidence from longitudinal studies of protective factors for adult psychosocial outcomes after cumulative childhood adversity (CA) in multiple domains. Although the authors focused solely on mediators, and protective factors can both be experienced at the same time as childhood adversity and potentially also act as moderators, we focus on their findings as a useful way to consider areas future researchers may wish to focus on. The focus the authors observed was that social support and education were the most common protective factors, followed by certain personality and dispositional factors. These will each be considered individually, in addition to the relevance of neurodevelopmental conditions to childhood adversity.

Social support

First, the authors found that social support acted as a protective factor for mental health outcomes, particularly depressive symptoms. Benefits were found from both social support quality and quantity individually, with greater effects combined than either on their own. These findings are consistent with the wider literature on social support as a protective factor for mental health in the context of trauma.^{Reference Xiong, Milios, McGrath and Kaltenbach8} The ‘buffering hypothesis’ posits that social support mitigates the negative consequences of stress when perceived availability of interpersonal resources is responsive to the needs elicited by stressful events. The ability to seek and accept comfort and help after stressful events is essential for healthy child and adolescent development. ACEs can disrupt the development of secure attachment relationships and limit access to necessary emotional and physical resources, making social support all the more vital. Social group membership, and the social identities and psychological resources these provide, may be particularly vital.

Education and academic attainment

Second, Buchanan et al^{Reference Buchanan, Walker, Boden, Mansoor and Newton-Howes7} also found that education and academic attainment were associated with improved outcomes for mental health, socioeconomic status and maltreatment perpetration. This is consistent with prior evidence supporting the protective influences of education, particularly for disadvantaged children, but delineating the unique contribution of specific aspects of education from confounders is complex. A prospective twin cohort study found a history of childhood maltreatment was associated with twice the risk for poor educational and occupational attainment.^{Reference Jaffee, Ambler, Merrick, Goldman-Mellor, Odgers and Fisher9} Interestingly, the presence of a supportive adult was protective for later occupational outcomes, highlighting the potential positive influence of teachers as mentors and role models. Duration of education is correlated with cognitive abilities with each additional year in education improving IQ by 1–5 points,^{Reference Ritchie and Tucker-Drob10} with implications for future employment and financial security. Moreover, childhood IQ predicts risk for adult psychopathology which may explain the protective influence of education.

Personality and dispositional factors

Third, Buchanan et al^{Reference Buchanan, Walker, Boden, Mansoor and Newton-Howes7} found that a variety of personality and dispositional factors were protective for mental health problems in adulthood. These included self-esteem, self-regulation, self-awareness, optimism, mastery and openness to experience. Previous research has largely reported negative cognitive factors, including maladaptive schemas, shame, negative core beliefs and self-criticism as mediating the childhood adversity–psychopathology relationship.^{Reference Aafjes-van Doorn, Kamsteeg and Silberschatz11} However, these are largely conceptually consistent. Mediation analyses should be interpreted with caution when considering whether these intrapersonal factors are in fact protective factors for mental health. ACEs can exert pervasive influences on personality development, and it is possible such intrapersonal factors may well reflect the response to adversity. Children exposed to adversity may develop mental schema and behaviours to adapt and survive in the context of adversity but which in other contexts are maladaptive and predispose to later psychopathology.

Neurodevelopmental awareness

An important additional domain relevant to the question of protective factors for cumulative childhood adversity is neurodevelopmental awareness. Children with neurodevelopmental conditions are at higher risk of experiencing severe adversities such as abuse and neglect, but mechanisms and directions of causality are still unclear and may be bidirectional.^{Reference Bali, Sonuga-Barke, Mohr-Jensen, Demontis and Minnis5} For example, behavioural genetic analysis suggests that abuse and neglect does not cause these heritable conditions (that include ADHD, autism and intellectual disability).^{Reference Dinkler, Lundström, Gajwani, Lichtenstein, Gillberg and Minnis12} Having a child with a neurodevelopmental condition can be stressful for parents and parental stress is an important risk factor for child abuse and neglect. However, there are certain extreme circumstances (e.g. very low stimulation institutional care or severe malnutrition) where severe early adversity does appear to cause neurodevelopmental conditions. Unfortunately, structural inequalities can also play a part in the interplay between neurodevelopmental conditions and adversity: if a child has experienced ACEs then they are at risk of a missed or late diagnosis of a neurodevelopmental condition – this is also true for Black children, who are more likely to have a delayed or missed diagnosis of autism or ADHD compared to White children.^{Reference Angell, Empey, Zuckerman, Hodapp and Fidler13,Reference Coker, Elliott, Toomey, Schwebel, Cuccaro and Tortolero14} An important strategy for increasing resilience in children who have experienced childhood adversity, therefore, is ensuring that children receive a holistic assessment covering both neurodevelopmental and trauma-related symptoms, being careful not to assume that any behavioural problems are ‘social’.^{Reference Hiller RM, Lewis, Minnis, Shelton, Tarren-Sweeney and Taussig15}

Translational implications for clinical practice

There is an urgent need for clinicians to be able to offer evidence-based interventions to prevent and treat ACE-related trauma symptoms. A treatment with established evidence in traumatised children and adolescents is trauma-focused cognitive behavioural therapy (TF-CBT). One challenge for clinicians is that children exposed to cumulative childhood adversity often develop severe and complex socioemotional difficulties. Waiting until problems have developed can mean adverse sequelae are more entrenched and difficult to treat. Early years mental health interventions are likely to be more effective due to more pliable infant brain neuroplasticity. We will discuss three novel interventions being evaluated in randomised controlled trials (RCTs).^{Reference Arnold and Webster16–Reference Minnis, Fisher, Forde, Atkinson, Crawford and McCullough18} The first is the New Orleans Intervention Model (NIM) for abused and neglected children aged 0–5 years in foster care, which is being compared with social work as usual in the BEst Services Trial (BeST)?^{Reference Arnold and Webster16} NIM is an infant mental health intervention offering attachment-focused assessment and intensive treatment to children in foster care and their birth families. If timely and adequate change is made, recommendations are made to the court about permanent return to birth families. If not, recommendation is made for adoption. Other interventions currently undergoing RCT evaluation include Dyadic Developmental Psychotherapy (DDP) in the Relationships In Good Hands Trial (RIGHT), intensive attachment-focused psychotherapy for adopted or fostered children aged 5–12 years with a history of maltreatment and relational difficulties;^{Reference Minnis, Turner-Halliday, Tapin, Ann Boyd, McConnachie and Henderson17} and the development of an Infant Parent Support (IPS) service for under-5s with a social worker and mental health concerns.^{Reference Minnis, Fisher, Forde, Atkinson, Crawford and McCullough18}

The need to harness protective factors for children with cumulative adversity is gaining political traction. The Scottish government has recently pledged £3.2 million towards infant mental health services, and the Royal College of Psychiatrists has recently published a report ‘Infant and early childhood mental health: the case for action.’ Nothing less will do for this group of patients.