Title: OveRcoming Adverse ChiLdhood Experiences (ORACLE)
Funder: Department of Health and Social Care

Abstract: This project seeks to improve outcomes for children and young people (CYP) experiencing the so-called Toxic Trio of parental mental health problems, substance misuse, domestic violence and abuse, and associated adverse childhood experiences (ACE) and risks, through prevention and improved support. This research will inform policy in health, social care, education, and criminal justice sectors, and is designed to achieve improvements in lifelong outcomes for children and young people at risk. CYP exposed to the Toxic Trio and associated risks are more likely to have poor outcomes. These problems can affect CYP and families throughout their lives, representing a waste of human potential, cost to society, and burden on health and social care. Existing evidence goes some way towards describing the nature and scale of problems facing CYP exposed to ACEs including the Toxic Trio. Traditional approaches that considered these problems in isolation have been unsuccessful. One reason may be a failure to recognise appropriately that these problems frequently co-exist in complex interdependent ways. There is insufficient evidence about the interactions between risk factors that shape outcomes, and insufficient evidence about effective interventions. Interventions to prevent and support CYP exposed to such complex problems need to designed with a more sophisticated approach to understanding how risks interact to affect CYP. Integrated systems-level responses need to be tested to address these structural, systems-level, community, family, and individual-level problems together. The theoretical basis for our proposal comes from syndemics, a conceptual framework that goes beyond conventional clinical and public health approaches, borrows from anthropology and builds on ecological and life-course frameworks. It acknowledges that health risks and problems tend to cluster among people who are already vulnerable because of economic determinants and other structural factors. Our hypothesis is that bi-directional relations occur between risk factors including structural determinants, and that we can better improve outcomes by addressing these issues in a way that accounts for this complexity and which recognises that poor health and health inequalities are the result of a multitude of interdependent elements within a connected whole. Therefore, we will apply a syndemics framework and systems approach to help understand the challenges facing CYP and families living in adverse conditions and guide us towards new insights and strategies for tackling health inequalities and poor outcomes in complex real-world contexts. We will incorporate data from multiple levels of analyses, using quantitative and qualitative research methods for a nuanced understanding of risk interactions, to better identify the most appropriate interventions to improve outcomes for vulnerable CYP and families. The work will be conducted in two phases. Phase 1 is about improving understanding. We will describe and analyse risks, experiences, needs, and outcomes; assess the current state of interventions; and highlight where evidence and previous work can inform our approach. Phase 2 is about designing a new evidence-based intervention to improve outcomes for children, young people, and families, together with a costed plan for evaluation to go forward for a proposed further project to test the intervention in practice.

Lay abstract: Across England, vulnerable children and young people are growing up with problems that affect their health and development, for example parents with mental health problems, who misuse drugs or alcohol, and violence in the family. These three risks are sometimes called the Toxic Trio, which with related problems known as Adverse Childhood Experiences, and together with other problems including poverty can have important effects on children s lives. Children and young people in risky environments have a higher chance of developing problems and less chance of good education, employment, and health in later life. Research so far focuses on problems, one at a time, rather than studying the whole environment around the child or young person. We think that the earlier children and young people receive support, the better their lives will likely be, but it is not clear how best to provide support. There is not enough known about what works to improve the life chances for children living with Toxic Trio and similar problems. The research we propose to do will investigate children and young people s needs in different communities, and will include families in difficulty, and children and young people in care settings. We will study the ways family and community environments affect children and young people, and what would help them. We ll also study what things make life more or less risky for children, and how that happens. We will use what we learn to design new and better ways to support children and young people. This project has two phases: first to better understand the health and lives of children and young people and then to design better ways to improve outcomes. We will talk confidentially with people to help us understand how we could do better, and we will use what we learn to design support that is as good as it can be. Finally, we will make a plan to test the new way of supporting children, young people, and families in order to learn whether it actually improves the lives and prospects of the children, young people, and families. We will work with the people most closely involved to be sure that we measure things that matter to them. We want to know how we can improve the lives of children and young people who live with Toxic Trio, other Adverse Childhood Experiences, and related problems. We believe this work will help children in need by providing evidence to help Government improve policy for children and families. Most importantly, our aim is to help children and young people at risk toward brighter futures, and to promote their wellbeing long into adulthood.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH