Submission by Tavistock Relationships to the Science and Technology Committee’s inquiry into Adverse Childhood Experiences, December 2017
We welcome the Science and Technology Committee’s inquiry into Adverse Childhood Experiences.
A leading researcher in the field of ACEs has argued that such experiences “should not be assumed to be isolated events in children’s lives. The common co-occurrence of ACEs is important clinically because the negative short- and long-term influence of ACEs on behaviors, emotional and social well-being, and physical health has repeatedly been shown to be cumulative. Therefore, researchers trying to understand the long-term health implications of childhood abuse may benefit from considering a wide range of ACEs” (Dong, 2004).
We agree with this statement, and in our submission we argue that as well as thinking about the common occurrence of ACEs, we should bear in mind that inter-parental conflict is a significant factor implicated in at least five of the adverse childhood experiences covered by the 10-item questionnaire.
While we acknowledge that poverty/financial strain is an important factor involved in adverse childhood experiences, it is noteworthy that the association between adverse childhood experiences and chronic disease and health service usage remains even after adjusting for deprivation (see, for example, Bellis, 2016), suggesting that there are other important factors involved in ACEs. Of these, we believe that the evidence concerning the impact on children of inter-parental conflict is such that interventions to address inter-parental conflict should play an important role in any strategies to reduce the incidence of such ACEs; and in the second part of our submission we describe some examples that we and others have developed.
Links between inter-parental conflict and adverse childhood experiences
Links between inter-parental conflict and emotional neglect
The Early Intervention Foundation’s review of the evidence on inter-parental conflict and children’s outcomes (Harold et al., 2016) found that “rather than operating as single influences on specific outcomes for children”, factors such as economic strain, parent psychopathology (e.g. depression), inter-parental conflict, negative parent–child relations, and parental divorce “may work in concert with each other, such that harsh economic conditions affect parents’ mental health, which adversely affects levels of couple relationship quality (i.e. inter-parental conflict), which in turn affects parenting practices, which then affect children’s symptoms of psychological distress”.
The review outlines how this model explains “how earlier environmental and economic influences impact parents’ ability to provide the type of home environment necessary for children’s long-term well-being” (Harold et al., 2016). The review authors continue: “While past research has focused on promoting positive parent–child relationships (predominantly mother–child relationships) as a primary site in remediating such family stress effects on children, this internationally replicated theoretical model highlights the quality of the inter-parental relationship as a central mechanism, filter, or conduit through which earlier family stresses (economic or social stress, parent mental health etc.) affect both parenting and children’s long-term psychological outcomes”.
The strength of the evidence presented in Harold’s review for the Early Intervention Foundation should necessitate, in our view, a much greater focus among policy-makers, researchers and practitioners on the impact of inter-parental conflict on parenting in relation to adverse childhood experiences - especially since one of the most salient characteristics of poor parenting practices is that of low warmth, something which so clearly maps onto the ACE questionnaire item on emotional neglect (i.e. ‘Did you often or very often feel that no-one in your family loved you or thought you were important or special?).
Links between inter-parental conflict and parental separation and divorce (characterised by high levels of conflict)
Research suggests that it is the manner in which parental separation or divorce is handled, rather than the event itself, that affects children more than the simple fact of whether their parents separate/divorce or not. A leading researcher in this field (Amato, 2000) has proposed a model in which divorce is considered a process rather than a single event. This model argues that events prior to divorce, such as parental conflict or lack of parental contact, can have major impacts on children more so than the legal dissolution of the marriage. Furthermore, there are a number of mediators or stressors brought on by the divorce process such as continuing discord with the former spouse, decline in emotional support, economic hardship and additional stressful events. The fact that 22% of couples with children under 16 are thought to be in relationships classified as ‘distressed’ (i.e. those which have a clinically significant negative impact on partner’s wellbeing, and which are characterised by partners regularly considering separation/divorce, quarrelling, regretting being in their relationship, being unhappy in their relationship, for example) indicates the magnitude of the problem (Sserwanja, 2016).
However, there is evidence (please see section ‘Interventions and approaches to reduce inter-parental conflict’ below) that the negative impacts of divorce can be mitigated through effective co-parenting, reduction of inter-parental conflict, and more emotional support.
Links between inter-parental conflict and alcohol misuse
While we acknowledge that there are many factors which contribute to alcohol misuse, it is important we believe to ensure that the role of inter-parental conflict is recognised among these. One study of 69 couples, for example, found that women tend to drink more than men in response to relationship difficulties and low levels of intimacy from their partner (Levitt, 2010). This finding echoed those from earlier studies which indicated that women whose relationships lacked intimacy reported increased drinking problems over time compared to women with more intimate relationships (Wilsnack, 1984). A longitudinal study however – which followed couples over a period of nine years – found that husbands, not wives, tend to drink in response to marital problems (Romelsjo, Lazarus, Kaplan, & Cohen, 1991). Other studies have demonstrated a greater likelihood of people abusing alcohol one year after scoring highly on a rating of marital dissatisfaction; while another study, of nearly 5,000 adults aged 18 to 64, showed that the marital discord underlying a divorce (rather than the divorce itself) to be associated with the onset of alcohol abuse, social phobia and chronic low mood (Overbeek, 2006).
Links between inter-parental conflict and mental illness
Again, while we acknowledge that a number of factors are implicated in parental mental health problems, we would like to highlight research which suggests that people who live in distressed and troubled relationships are three times more likely to suffer from mood disorders (e.g. depression), and two and a half times more likely to suffer from anxiety disorders, as people who do not experience such relationship distress (Whisman and Uebelacker, 2003).
For example, authors of a seminal study conducted in 1999 of over 900 married individuals who at the start of the study were classified as not having major depression concluded that ‘20% to 30% of new occurrences of major depressive episodes could be prevented if marital dissatisfaction could be eliminated’ (Whisman, 1999).
In other research, a study of nearly 5,000 adults showed that the quality of a person's relationships with their partner predicts the likelihood of major depression disorder in the future (Teo, 2013). This research found that one in seven adults with the lowest-quality relationships were likely to develop depression as opposed to one in 15 with the highest quality relationships; and that people with unsupportive partners were significantly more likely to develop depression, whereas those without a partner were at no increased risk.
Links between inter-parental conflict and domestic violence
Michael Johnson’s widely-adopted typology of domestic violence posits a range of such violence that ranges from coercive/controlling to situational. Situational couple violence is characterised by violence that occurs because a couple has conflict which turns into arguments that can escalate into emotional and possibly physical violence (Johnson, 2008).
Situational couple violence is much more prevalent than domestic violence of the coercive, controlling type. The fact that low level (in relative terms) conflict can and does escalate into physical violence illustrates how inter-parental conflict can be a pre-cursor to this kind of behaviour.
Research estimates that in 40% of couples characterised by this type of violence, the situational couple violence comprises one incident (such as a slap, or a push) only, and there is no further violence within the relationship. For the remainder, there is chronic violence (ranging from a few incidents per year to chronic arguing that frequently turns to violence).
Our clinical experience, which is confirmed by a growing evidence base (Tavistock Relationships, 2015a), strongly suggests that inter-parental conflict can often be a pre-cursor to violent conflict. The implications of this in terms of interventions are explored below.
Interventions and approaches to reduce inter-parental conflict
In light of the links highlighted above between inter-parental conflict and a number of the adverse childhood experience covered by the ACE questionnaire (i.e. emotional neglect, highly conflictual parental divorce and separation, alcohol misuse, mental illness, domestic violence), we would like to draw the inquiry’s attention to a range of interventions which are effective at reducing inter-parental conflict and improving parental relationship quality.
Reducing inter-parental conflict in the context of parenting
The Early Intervention Foundation’s Commissioning Guide: Reducing the Impact of Inter-parental Conflict on Children provides information for local authorities on a range of interventions which have proven to be effective at improving parental relationship quality, including a number of which do so in the context of addressing parenting issues (http://www.eif.org.uk/publication/eif-commissioner-guide-reducing-the-impact-of-interparental-conflict-on-children/ ). Schoolchildren and their Families (the U.S. name for the Parents as Partners (see listing on the Early Intervention Foundation’s Guidebook http://guidebook.eif.org.uk/programme/schoolchildren-and-their-families)) is one of these programmes. Evaluation of the this 16 week groupwork programme for parents or co-parents has shown improvements to quality of the couple relationship (with the greatest improvements in those clients who had poor quality and high-conflict relationships at enrolment), reduction in violent problem-solving; improvements in psychological wellbeing; reduction in children’s emotional and behavioural difficulties, with most striking improvements seen in children with the most problematic behaviours (Casey, 2017).
Reducing couple conflict in the context of divorce and separation
The importance of improving the quality of the co-parenting relationship between separated or divorced parents has increasingly been recognised by policy-makers and practitioners in recent years. Tavistock Relationships has, like a number of organisations in this field, trialled approaches in this area. For example, our Parents in Dispute programme, run in association with Cafcass, was successful in improving the parenting alliance between separated couples locked in entrenched conflict, played out through the court system over many years, regarding the co-parenting arrangements for their children. Evaluation of this intervention demonstrated that a relationship-focused intervention can be effective at engaging parents in joint sessions (a significant achievement in and of itself) as well as significantly improving their capacity to co-parent effectively. Mothers participating in the intervention also reported a significant reduction in terms of global psychological distress, as measured by the CORE Outcome Measure, which is another important factor for children’s wellbeing (Tavistock Relationships, 2015b).
Reducing inter-parental conflict in the context of alcohol misuse
Research shows that couple therapy is effective (and indeed more effective than individual treatment) at increasing abstinence and improving relationship functioning among people with alcohol problems (O’Farrell, 2003). Indeed, a randomised controlled trial (Fals-Stewart, 2006) comparing individually-based treatment, the provision of psycho-educational material and couple therapy found that, at 1-year post-treatment follow-up, participants who received couple therapy reported fewer days of drinking, fewer drinking-related negative consequences, higher dyadic adjustment, and reduced partner violence than those who received individually-based treatment or psycho-educational material.
Reducing inter-parental conflict in the context of mental health
In terms of interventions which work with couples, an evaluation of877 individually and relationally distressed participants who completed at least two sessions of psychodynamic couple therapy and completed self-report measures assessing psychological well-being (CORE-OM) and relationship quality (Golombok Rust Inventory of Marital State, GRIMS) showed an overall significant decrease in individual psychological distress for both male and female clients at the end of therapy, with a large effect size of d = −1.04. There was also a significant improvement in relationship satisfaction for both male and female clients, with a medium effect size of d = −0.58 (Hewison, 2016). It is also noteworthy that Couple Therapy for Depression, the NICE-recommended therapy for depression in context of relational difficulties, achieves the highest recovery rates of all psychotherapy therapies available in IAPT (http://digital.nhs.uk/catalogue/PUB22110 ).
Reducing couple conflict in the context of domestic violence (situational couple violence)
There is a great deal of established practice, and some research, which suggests that couple therapy can be appropriate for some couples (Antunes-Alves and Stefano, 2014) (Stith, 2012) to address couple conflict in the context of situational couple violence. For a discussion of the issues involved in couple work to address situational couple violence (domestic violence), please see Working relationally with couples where there is situational violence: a policy briefing paper from The Tavistock Centre for Couple Relationships (Tavistock Relationships, 2015a).
During 2015-16, Harrow Children’s Services partnered with Tavistock Relationships to deliver a feasibility project trialling a mentalization-based couple therapy approach to intervention with couples who are parents of one or more Children in Need where there is situational violence between the partners. The aim of the Project was to assess whether this intervention is safe, helps alleviate the incidence of violence, improves the couple relationship, and improves outcomes for children. Evaluation of the project found that not only is it possible to deliver a couple therapy intervention to carefully assessed and selected parents with a history of domestic violence safely and productively, but that working together as a couple did not lead to any further incidents of domestic violence; as a result of which a number of couples who had been on Child Protection Plans were stepped down to Child in Need Plans, while two couples whose children had been on Child in Need Plans improved and their cases were closed (summary report and outcomes available upon request).
There is also evidence that the groupwork programme Supporting Father Involvement (known as Parents as Partners in the UK) is an appropriate and effective intervention for families at risk of low severity domestic violence and abuse since evaluation of the programme has shown that is reduces violent behaviours (including hitting and screaming) in families with relatively high levels of conflict (http://www.eif.org.uk/publication/early-intervention-in-domestic-violence-and-abuse/ ).