Service needs of young people affected by adverse childhood experiences (ACEs): A systematic review of UK qualitative evidence.

BACKGROUND: Adverse Childhood Experiences (ACEs) such as, physical and sexual abuse, neglect, or living in a household with domestic violence or substance misuse, can have negative impacts on mental and physical health across the lifecourse. A deeper understanding of the kinds of services that people affected by ACEs feel they need to overcome these negative impacts is required. REVIEW QUESTION: How do people affected by ACEs between the ages of 3 to 18 experience support and services in the UK? What are their needs relating to services and support?
METHODS: Systematic review of qualitative evidence. We harvested relevant studies from existing systematic reviews of qualitative evidence located through a search of 18 databases. Included studies needed to be published in or after 2008, conducted in the UK, and report the views of people exposed to ACEs relating to their service needs. We included studies with participants who were affected by ACEs between 3 and 18 years old with no restriction on the age at which they accessed services.
RESULTS: We identified 71 reviews from which we harvested 238 references on title and abstract screening. Following full text screening and quality and relevance appraisal we included 20 studies. Each of the included studies focussed on a specific ACE population. Almost half focused on young people who were fostered, looked-after or leaving care. No studies focussed on parental incarceration or divorce. Young people value emotional and practical support. Service providers were most valued for displaying empathy, being non-judgemental, and being active listeners. Supportive relationships, especially with adults, are a key factor in feeling understood.
CONCLUSIONS: People affected by ACEs describe the importance of stability and continuity in the support they receive. These factors are important for allowing necessary time to overcome obstacles and build up trust. Research often frames response to ACE in terms of short term individual psychological outcomes but these findings highlight the importance of focussing on wider social factors to encourage meaningful engagement with services.

Introduction

Adverse Childhood Experiences (ACEs) have been defined as stressful experiences occurring during childhood that directly harm a child or affect the environment in which they live. They represent a variety of negative experiences; for example, physical and sexual abuse, and neglect; or growing up in a house with a harmful family environment as a result of domestic violence or substance abuse (Bellis, Ashton, & et al., 2015). While the complex nature of ACEs mean that prevalence is challenging to determine, studies in the UK have found that just under 50% of the population report at least one ACE (Bellis et al., 2014, Bellis et al., 2015b). The different types of ACEs appear to be highly correlated, with people reporting one ACE much more likely to also report others (Finkelhor, 2018; Ford et al., 2014). Depending on circumstance (such as age at onset, severity or duration of ACE(s), access to resources) not all young people who experience ACEs will be negatively impacted, or affected by ACEs in the same ways (Kelly-Irving & Delpierre, 2019). However, individuals who experience ACEs are at greater risk of poor mental and physical health outcomes, and even premature mortality compared with those who do not experience ACEs (Hughes, Lowey, Quigg, & Bellis, 2016).

Preventing recurrence and reducing the harms associated with ACEs is a key priority for public health policymakers in the UK (Scottish Government (2017) (2017), 2017; Welsh Government, 2015, 2015, 2015). Evidence on the effectiveness of different services for people affected by ACEs is therefore vital. However, a recent overview of systematic reviews on the effectiveness of interventions that mitigate the harmful impacts of ACEs (Lorenc, Lester, Sutcliffe, Stansfield, & Thomas, 2020) found limited consistent review-level evidence for the effectiveness of many interventions for children and young people who have experienced ACEs. The authors found that most of the included systematic reviews examined the effectiveness of individual-level psychological interventions, such as Cognitive Behavioural Therapy, for improving the mental health of young people affected by ACEs.

By contrast the overview revealed a dearth of systematic reviews concerning social or community-level interventions and little evidence about important outcomes such as housing, education and employment, drug use or criminal involvement. Similarly, a recent systematic review by Marie-Mitchell and Kostolansky (2019) concluded that whilst multicomponent health interventions that utilize professionals can reduce child behavioural and mental health problems associated with exposure to ACEs, there is a need for further research to evaluate the impact of a broader range of interventions including expanded parenting education, social support for families and linkages to home-visiting programs.

The limited systematic review evidence on the broader range of interventions and outcomes for those affected by ACEs echoes concerns about the decontextualised way in which ACEs are discussed in research and policy, where emphasis is often placed on individual pathology rather than structural factors (Kelly-Irving & Delpierre, 2019; Taylor-Robinson, Straatmann, & Whitehead, 2018). A deeper understanding of service needs is vital for identifying avenues for future research, intervention development from a service-user perspective, and for understanding future priorities for intervention investment. Service users’ views are vital for understanding how particular interventions or intervention features meet service user needs (Sutcliffe et al., 2018) and the degree to which services take account of users’ priorities and desired outcomes (Beresford et al., 2008). The views of children have been shown to be particularly important as they may identify needs and priorities that adults do not anticipate (Thomas et al., 2004). Qualitative evidence synthesis (QES) brings together the findings from multiple qualitative research studies in order to establish a greater understanding of issues that are subtle or sensitive in nature (Flemming, Booth, Garside, Tunçalp, & Noyes, 2019). Whilst many QES regarding services for ACE populations have been conducted these largely focus on the service needs and experiences of a specific ACE population such as those who have experienced sexual abuse (Parry & Simpson, 2016) homelessness (Connolly & Joly, 2012), parental mental illness (Bee et al., 2014) or being in the care system (Dickson, Sutcliffe, Gough, & Statham, 2009). However, by drawing on multiple studies QES has the capacity to reflect a diversity of perspectives that may not be present in a single study (Carroll & Booth, 2015). By bringing together evidence from multiple and diverse ACE populations we hope to provide both a broader picture of the range of service needs and, given the high correlation between different ACEs, a more nuanced understanding of the complex needs of people affected by ACEs.

The QES findings reported here is a discrete section of a larger evidence review What Helps to support people affected by Adverse Childhood experiences? A review of Evidence (Lester et al., 2019) which was commissioned by the National Institute for Health Research (NIHR) Policy Research Programme (PRP) for the Department of Health and Social Care (DHSC). This review comprised three components – an overview of systematic reviews of interventions, consultation with young people, and a qualitative synthesis. The authors found stark discrepancies between the ways in which interventions in the overview of systematic reviews were framed to support people affected by ACEs and the types of support and services which young people in the consultation and qualitative synthesis described needing. The purpose of this paper is to disseminate findings from a focussed section of the qualitative synthesis demonstrating the kinds of services which people affected by ACEs in the UK most value and how they can best be delivered to suit their needs.

Aims and review questions

The purpose of this study was to gain a deeper understanding of the kinds of services that young people exposed to ACEs feel they need. We synthesised qualitative evidence from the UK to answer the following questions:

How do people affected by ACEs between the ages of 3–18 experience support and services in the UK? What are their needs relating to services and support?

Methods

Design

We conducted a systematic review of qualitative evidence. The review protocol was registered in PROSPERO (registration CRD42018092192). EPPI-Reviewer 4 software was used to manage data. The project received full ethical approval from UCL IOE Research Ethics Committee (REC 1077).

Study identification

Given the large number of existing qualitative reviews and the broad population focus of this review, we identified relevant studies from existing systematic reviews of qualitative evidence that were identified as part of a systematic review of systematic reviews (Lester et al., 2019). Harvesting research from existing systematic reviews offered a robust approach for study identification since it builds on existing systematic searches and screening. The approach was also advantageous in terms of efficiency as drawing on multiple systematic reviews enabled a broad set of potentially relevant studies to be examined without having to sift through thousands or tens of thousands of studies from bibliographic database searches. However, as stated in the limitations section, using only studies identified in this way risks missing the most recent studies relevant to the review question.

Searches and inclusion criteria for systematic reviews

In March 2018, 23 bibliographic databases and other online resources were searched to locate all types of systematic reviews of research on adverse experiences in children and young people published in English since 2007. The resources focused on research literature across the fields of healthcare, mental health, social care, social science, education, child and adolescent development, and systematic reviews. These are listed along with an example search strategy in Appendix B. Papers identified by the searches were screened for inclusion if they were a systematic review (i.e. with a clearly defined search strategy and explicit inclusion criteria) and if they included qualitative studies on the views of one or more ACE populations. An initial sample of 10% of abstracts were screened independently by two reviewers. Agreement on this sample was 98.3% and the remaining abstracts were screened by a single reviewer. Full text references were screened by two reviewers independently with any differences resolved by discussion.

We based our definition of ACE populations on the one used by the US Centres for Disease Control (CDC) (Felitti et al., 1998) which includes: people directly affected in childhood by sexual, physical or emotional abuse or neglect and children whose parents are affected by intimate partner violence, incarceration, mental health problems or drug and alcohol abuse. We extended this definition, drawing on the findings of more recent UK research (Allen & Donkin, 2015) and discussions with the policy team at DHSC to include children affected by parental bereavement, looked-after children and homeless children and young people. We considered a range of other possible childhood adversities (Mersky, Janczewski, & Topitzes, 2017) but carved our parameters by focussing on ACEs which were most closely related to household dysfunction.

Identification procedure and inclusion criteria for primary studies

The references of all the qualitative studies included in each review were identified and imported into EPPI-Reviewer (Thomas, Brunton, & Graziosi, 2010) for screening. Where systematic reviews included both qualitative and quantitative studies, those that were clearly identified as not being qualitative studies were not imported. Similarly, those clearly identified as not originating from the UK were not included in our set. The references were first screened based on the title and abstract. Two reviewers independently screened 10 percent of identified references and since the rate of agreement was over 90 percent the remaining titles and abstracts were screened by a single reviewer. References that were deemed potentially relevant were then retrieved and screened using the full text. All full texts were screened independently by two reviewers with any disagreements resolved by discussion. We included qualitative studies from the UK reporting the views of people exposed to ACEs between the ages of 3 to 18 about their service needs, including those who accessed services in adulthood. As prevention of ACEs was beyond the remit of our review, we did not include early years services, or interventions aimed at parents with children under the age of 3. Included studies needed to be published in or after 2008 and report details of the qualitative data collection and analysis methods used. To ensure relevance to UK practice we focussed on UK studies only. We used 2008 as a cut-off date to ensure we captured studies where the effects of public sector funding cuts on services in the decade following the financial crash would be evident.

Quality and relevance appraisal

Included studies were appraised using criteria developed and used in previous QES (Rees, Oliver, Woodman, & Thomas, 2009; Shepherd et al., 2010) and informed by principles of good practice for conducting social research with the public (Harden et al., 2004). The quality of each study was considered according to:

the rigour of sampling, data collection and data analysis;

whether study findings were grounded in/supported by data;

whether the breadth and depth of findings were appropriate for the review;

whether young people’s perspectives and experiences were privileged.

Based on the above criteria the overall quality of each study was rated as either high, medium or low. Each study was then rated as having high, medium or low relevance based on the match between the study aims, sample and findings and our review question. An overarching rating of study ‘usefulness’ was then made based on the assessments for both quality and relevance. Table 1 below shows the algorithm for overall ‘usefulness’. Since a large number of studies on looked after children (LAC) were identified we included only those achieving a ‘gold standard’ usefulness rating, for other ACE populations we included those receiving either a ‘high’ or ‘gold standard’ usefulness rating. The full appraisal tool can be found in Appendix C. All quality and relevance appraisal was conducted by two reviewers working independently; disagreements were resolved by discussion.

Table 1

Algorithm for overall ‘usefulness’ rating based on reliability and relevance.

Usefulness rating	Criteria
Gold standard	A ‘high’ rating for both quality and relevance.
High	One ‘high’ and one ‘medium’ quality and relevance rating.
Medium	A ‘medium’ rating for both quality and relevance.
Low	A ‘low’ rating for either quality or relevance.

Data extraction and synthesis

We extracted data on the aims of each study; the number of ACE population participants and whether there were other participants (e.g. parents/carers or service providers); the characteristics of ACE population participants (age, sex, ethnicity, socioeconomic status and family background); the key themes noted by the authors; and the findings reported by authors including that relate specifically to ACE population views – i.e. participant quotes, author descriptions and author discussion and conclusion points (findings relating to parents/carer or service provider views were not extracted).

Thematic synthesis (Thomas & Harden, 2008) was used to inductively code and synthesise the findings of included studies. Three reviewers read and re-read each paper and applied line-by-line coding to capture descriptive themes. Meetings were held to discuss and refine emerging themes and to develop analytical themes that directly answered the review question. Due to the large number of studies on LAC populations we first synthesised findings from studies focusing on other ACE populations so as to avoid LAC studies dominating or skewing our interpretation of the data.

Results

Flow of literature through the review

We identified 71 reviews from which we identified 238 references. Following full-text screening and quality and relevance appraisal 20 studies with findings on service needs were included in our analyses. As noted above, the original review had a broader focus than just service needs and included qualitative papers with no data on service needs. As such we have amended exclusion criterion 3 from the original review to reflect the narrower focus of this paper. Fig. 1 below documents the results of screening and quality appraisal.

Fig. 1

Flow of literature through the review.

Characteristics of included studies

The 20 studies involved a total of 283 participants affected by ACEs. Sample sizes ranged from four to 50 participants with most studies having between 10 and 25 participants. Six studies included the views of other stakeholders such as parents or service providers, but findings reported here relate exclusively to the characteristics and views of participants with ACEs.

Each of the studies focused on a specific ACE population. Almost half of the studies focused on young people who were fostered, looked-after or leaving care (n = 9). Other studies focused on people who had experienced: sexual abuse (n = 3); parental mental illness (n = 3); parental drug and alcohol misuse (n = 2); ; abuse (unspecified) (n = 1); parental bereavement (n = 1); and homelessness (n = 1). Of the 11 studies which did not focus on looked after children or young people the participants were from a range of service experience backgrounds – some were involved with social services and others were involved with independent services e. g for young carers, for young people who were parentally bereaved, or therapy for women who have experienced child sexual abuse. No studies focused on people who had experienced parental incarceration, divorce or domestic violence. Whilst some studies indicated that participants may have experienced multiple ACEs only one explicitly documented the details and none aimed to focus on participants with multiple ACEs.

Most studies focused on young people (n = 17), while a small number focused on adult survivors of child sexual abuse (n = 3). Of the studies focused on young people eight focused predominantly on older adolescents and care leavers (i.e. those aged 16 years or older), six focused predominantly on senior school-aged children (i.e. those aged 11–16 years) and just two studies included younger participants aged below 11 years. One study on young people did not specify their ages.

Nine studies did not specify the ethnicity of participants, six reported their participants to be exclusively white British and the remaining five reported participants from a range of ethnic backgrounds. One study specifically focused on the experience of young people from a minority ethnic background. Most studies included both males and females (n = 16), while three studies focused on females only. One study did not state the sex of participants.

Further information on included studies, including quality and relevance appraisals, is provided in Appendix A.

Thematic analysis

The synthesised findings were grouped into three sections as outlined in table 2 . The first two sections (4.3.1, 4.3.2) relate to the types of services which were valued, and the third section (Section 4.3.3) relates to how services could best be delivered to meet the needs of people affected by ACEs.

Table 2

Main findings by theme.

Service need: emotional support	Connections and interactions with peers produce a shared sense of solidarity, and supportive relationships with adults played a key role in forming positive experiences of services.
Service need: information and practical advice	People affected by ACEs required practical advice and information, such as help with understanding parents’ mental health diagnoses, and clarity and transparency over social service processes.
Service delivery: how services are delivered	An injured ability to trust, brought about through cumulative experiences of being let down, meant that it took time and sensitivity for professionals to earn the confidence of people affected by ACEs. People affected by ACEs most valued organisations and professionals which offered flexible, dependable support delivered in a way which bestowed a sense of autonomy and control to the service user.

Service need 1: Emotional support

Given the emotional pressures that ACEs inflict on the lives of young people and the social isolation they may experience, it is unsurprising that one of the most desired features of services was the provision of supportive relationships. All 20 studies noted the value of supportive relationships either with other young people or with adults.

Across the 20 studies 17 authors’ conclusions focused specifically on the need for those who have been exposed to ACEs to have access to supportive, trusting relationships (Barn, 2010; Chouliara et al., 2011; Collins & Barker, 2009; Driscoll, 2013; Fraser, McIntyre, & Manby, 2009; Gaskell, 2010; Grant, Repper, & Nolan, 2008; Griffiths, Norris, Stallard, & Matthews, 2012; Houmoller, Bernays, Wilson, & Rhodes, 2011; Jobe & Gorin, 2012; Luke & Coyne, 2008; Madigan, Quayle, & Cossa, 2013; Matthews & Sykes, 2012; McMurray, Connolly, Preston-Shoot, & Wigley, 2011; Montgomery, Pope, & Rogers, 2015; Munro, Lushey, & Ward, 2012; Winter, 2010). Supportive relationships with professionals were described as ‘the cornerstone’(Grant et al., 2008) of effective engagement and service delivery

Relationships with peers, whilst an invaluable source of support for some, were challenging for others due to stigma, shame and practical issues. As such, services may be an important avenue for fostering much needed peer support among young people. In each of three studies focused on therapeutic group support (Brewer & Sparkes, 2011; Grant et al., 2008; Saha, Cheung Chung, & Thorne, 2011) authors emphasised that opportunities to develop peer relationships were universally valued by participants.

“All 10 young people we interviewed talked with enthusiasm about their experiences of group work in all its forms, and of the opportunities and benefits it brought to them.” (Grant et al., 2008, author description)

Connecting young people who had faced similar adversities was experienced as an important mechanism for addressing feelings of stigma and shame.

“Being where you were with so many people in the same situation, there were a lot of emotions flying but in a good way and there was never any embarrassment about letting yourself feel upset.” (Brewer & Sparkes, 2011, young person)

This element of peer support was also valued by a young person who had experience of being in a care home: “In a children’s home everyone has something in common and it’s like ‘oh why are you here then, what’s your story’ you know.” (Gaskell, 2010, p. 141)

A sense of ‘shared experience’ (Griffiths et al., 2012; Houmoller et al., 2011), ‘solidarity’(Saha et al., 2011) or common identity (Grant et al., 2008) with peers was considered important in helping people to overcome the emotional impact of ACEs. In one study on victims of sexual abuse sharing experiences in a group setting an author noted that participants “changed their negative self-attributions, minimised their self-blame and unburdened themselves from feelings of guilt and responsibility for abuse” (Saha et al., 2011, author description). This experience was seen as vital for helping people rebuild a positive self-identity, for example:

“Each participant acknowledged that the group programme had helped them ‘take control back’ of their lives by helping them to ‘regain’ their sense of power, self, strength and identity.” (Saha et al., 2011, author description)

The majority of studies (n = 13) noted the ability of formal services to provide support, either through foster carers (Barn, 2010; Driscoll, 2013; Madigan et al., 2013; Matthews & Sykes, 2012) or a range of other types of professionals including social workers (Fraser et al., 2009; Houmoller et al., 2011; Jobe & Gorin, 2012), project workers (Grant et al., 2008), support workers (Houmoller et al., 2011), outreach workers (McMurray et al., 2011), leaving care personal advisers (Munro et al., 2012), therapists (Chouliara et al., 2011), healthcare professionals (Griffiths et al., 2012; Montgomery et al., 2015), and teachers (Driscoll, 2013; Fraser et al., 2009; Houmoller et al., 2011).

Given the nature and significance of this supportive role, many studies appeared to echo a theme identified in the paper by Griffiths and colleagues that “not just anyone can help” (p. 77). The attributes that such adults needed in order to provide appropriate social support seemed to be more important than their profession. Attributes commonly expressed as vital for providing support were: displaying empathy (Chouliara et al., 2011; Collins & Barker, 2009; Fraser et al., 2009; Grant et al., 2008); being non-judgemental (Brewer & Sparkes, 2011; Chouliara et al., 2011; Collins & Barker, 2009); and being active listeners (Chouliara et al., 2011; Collins & Barker, 2009; Fraser et al., 2009; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Winter, 2010).

“You’ve got to feel like you can tell them stuff and they’ll know where you’re coming from and wouldn’t judge you for it. And they’ve got to be able to listen. Some people just don’t want to hear what you’ve been through and just want you to be happy all the time. You can’t really talk to someone like that.” (Collins & Barker, 2009, young person)

In addition to describing specific attributes, young people in six studies (Chouliara et al., 2011; Collins & Barker, 2009; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; McMurray et al., 2011) explicitly described needing to feel that professional adult support came from a genuine sense of caring ‘not just some act they’re putting on’(Collins & Barker, 2009). In one study it was described as ‘beyond the boundaries of professional duty’(Driscoll, 2013) and a number of studies referred to the type of support needed as being akin to parental support (Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011). For example, a young person supporting a parent with mental illness said:

“Come to think of it now, I suppose they (project workers) are like parents, like parent figures that you can depend on when your mum can’t do it for you. The sort of stuff your mum can’t do for you they do for you.” (Grant et al., 2008, young person)

Four studies on foster care (Barn, 2010; Gaskell, 2010; Luke & Coyne, 2008; Madigan et al., 2013) highlighted how a sense of authentic caring was key to supporting a young person’s self-identity. Foster carers were praised for welcoming young people “As part of the family, instilling in them a sense of belonging”’ (Luke & Coyne, 2008).

Several papers (Collins & Barker, 2009; Houmoller et al., 2011; Jobe & Gorin, 2012) highlighted how teachers constitute a very visible source of adult support for young people, with several young people reporting receiving both effective (Collins & Barker, 2009; Houmoller et al., 2011; Jobe & Gorin, 2012) and disappointing, (Jobe & Gorin, 2012) support from teachers. These findings suggest that training and support for teachers to act as both supportive adults and a conduit to receiving other forms of support may be an effective option.

Service need 2: Practical support

In addition to the need for social and emotional support, a common theme across the studies was a need for practical support to address the challenges they faced. Forms of practical support from services that participants identified as potentially helpful included information to help them understand and address their problems, practical advice to help them manage everyday challenges and respite from the challenges they faced.

Participants in ten studies highlighted a view that services might help by providing information (Bee, Berzins, Calam, Pryjmachuk, & Abel, 2013; Brewer & Sparkes, 2011; Chouliara et al., 2011; Fraser et al., 2009; Gaskell, 2010; Grant et al., 2008; Griffiths et al., 2012; Jobe & Gorin, 2012; Matthews & Sykes, 2012; Winter, 2010). In three studies young people with parents with mental health problems (Bee et al., 2013; Grant et al., 2008; Griffiths et al., 2012) felt information about mental illness would have been valuable in helping them to cope. The authors of one study concluded:

“Low mental health literacy was uniquely and consistently identified as exerting a negative impact on children’s abilities to cope with and respond to their parent’s mental illness.” (Bee et al., 2013, author conclusion)

Similarly, in a study about parental bereavement participants indicated that they would have valued information about what they might expect to experience in grieving for their parent (Brewer & Sparkes, 2011).

In some studies participants expressed a need for information about which services are available to them and better information about the services they are currently receiving. In four papers(Bee et al., 2013; Chouliara et al., 2011; Collins & Barker, 2009; Jobe & Gorin, 2012) young people expressed frustration that they were unaware of services that could provide support; as one young person described “I don’t know much about services for people like me” (Collins & Barker, 2009). The authors of this study described the lack of awareness of sources of help as ‘one of the most striking aspects’ (Collins & Barker, 2009) of young people’s accounts. Other authors also commented on the lack of visibility of services for young people in need. For example:

“Some young people were unclear which professionals they could have approached for help and felt that professionals who might be able to help were not visible to them when they were looking for someone to disclose to.” (Jobe & Gorin, 2012, author description)

Young people expressed frustration about the lack of information regarding the nature of services with which they were already engaged (Chouliara et al., 2011; Fraser et al., 2009; Gaskell, 2010; Jobe & Gorin, 2012; Matthews & Sykes, 2012; Winter, 2010). For example, abrupt changes to care without warning: “you get a letter saying ‘I’m sorry I’m not going to be your social worker anymore’, and you think hang on, I’ve never even seen you!”(Gaskell, 2010). One young person highlighted an extreme example of this “nobody explained why they were taking me away.” (Fraser et al., 2009, young person).

Victims of abuse experienced child protection services as a ‘blunt instrument’ (Chouliara et al., 2011) when information was not provided. Another study described how a lack of information about the consequences of disclosure of abuse and social care procedures could lead to young people not disclosing their situation:

“Fears about being placed ‘in care’ often led young people to holding back information from professionals. A number of young people were concerned about and unsure what would happen if they did tell someone about their maltreatment and of the consequences for themselves and/or their families.” (Jobe & Gorin, 2012, author description)

In a study on parents with mental health problems young people described feeling ‘out of the loop’ about how support for their mothers was being organised which hindered their ability to query reasons for interruptions to that support (Grant et al., 2008). As one author concluded – this finding is not new – and that research continues to highlight:

“The need to target more information at young people about forms of abuse and where to seek help […] Young people also lack information about what is happening to them once they are in the child protection system and about the roles of individual professionals” (Jobe & Gorin, 2012, author description)

A theme identified in seven studies was the need for support with handling practical responsibilities and problems (Bee et al., 2013; Collins & Barker, 2009; Driscoll, 2013; Gaskell, 2010; Grant et al., 2008; Madigan et al., 2013; Montgomery et al., 2015).

In each of these studies young people reported having to take on responsibilities not usually expected of children, such as ‘housing and money’ (Collins & Barker, 2009), ‘completion and return of forms sent to families by schools, the benefits agency and so on’ (Grant et al., 2008) or ‘to get a bed somewhere, to get your benefits working right’ (Collins & Barker, 2009). In one study a young person described this sort of support as “The thing that’s helped the most … Like if I’m getting chucked out of college or there’s something happened at college and I don’t know how to work something out … (project worker) will get on to the college straight away.” (Grant et al., 2008). One young person living with parental mental illness identified how taking on these responsibilities was a huge challenge in the day to day life of young people but one that could easily be mitigated with the right support: “Problems that might sometimes seem small, or perhaps smaller if they were solved.” (Bee et al., 2013, young person).

In four studies young participants indicated the value of services that provided some respite from their troubles (Bee et al., 2013; Brewer & Sparkes, 2011; Grant et al., 2008; Houmoller et al., 2011).

“There were lots of comments about the value of group activity in diverting participants from constantly thinking about their families and their caregiving responsibilities, and from the associated stresses.” (Grant et al., 2008, author description)

Recreational and creative activities such as music (Bee et al., 2013) and sport (Brewer & Sparkes, 2011), and the act of “[doing] something different, completely different that takes your mind off it”(Brewer & Sparkes, 2011) were noted for their dual benefits of relieving stress and providing opportunities for socialising.

Service need 3: Service delivery

In addition to the question of ‘what kinds of services are needed’ the data suggest that ‘how services should be delivered’ may be fundamental to their uptake.

Nine studies (Chouliara et al., 2011; Collins & Barker, 2009; Driscoll, 2013; Fraser et al., 2009; Gaskell, 2010; Grant et al., 2008; Jobe & Gorin, 2012; Madigan et al., 2013; McMurray et al., 2011; Montgomery et al., 2015) indicated the vital significance of trust, by referring to it as a ‘necessary’(Collins & Barker, 2009), ‘important’(Chouliara et al., 2011) or ‘fundamental’(Grant et al., 2008) precursor for effective relationships with service providers. As several authors pointed out children exposed to ACEs have typically experienced ‘rejection and abandonment’ (Collins & Barker, 2009) such that mistrust is only to be expected. As one young person explained:

“And if you … can’t even trust your own mother you are going to need more than someone coming around saying ‘‘I’m a social worker’’.… It’s going to need more than a name and a nice smile and a cup of coffee.” (Driscoll, 2013, young person)

In seven studies (Collins & Barker, 2009; Driscoll, 2013; Fraser et al., 2009; Grant et al., 2008; Jobe & Gorin, 2012; Madigan et al., 2013; Montgomery et al., 2015) participants described a reticence to engage with services due to previous negative experiences. Participants in the study with homeless adolescents (Collins & Barker, 2009) found that they “almost universally mistrusted formal sources of help” and that many had been advised by others to mistrust services.

“Personally, I usedn’t to get involved with social services. Purely because when I was young my mum used to tell me that the social services were bad people and that if ever I complained to them about my mum that they would take me away from her.” (Collins & Barker, 2009, young person)

Thus while the attributes of valued service providers are described above, one author concluded that practitioners also need “to be aware of issues concerning rejection and abandonment along with the consequent hurt, rage and mistrust.” (Collins & Barker, 2009)

In eight studies continuity and dependability arose as important themes relating to trust (Chouliara et al., 2011; Collins & Barker, 2009; Driscoll, 2013; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Luke & Coyne, 2008; Munro et al., 2012). Across the studies young people voiced misgivings about services when relationships with professionals were not continuous or could not be relied upon to deliver support:

“-I don’t see the point of having Social Workers.

-No?

- ‘Cause they don’t really help and they just leave you after a while” (Houmoller et al., 2011, young person)

It was noted in six studies (Chouliara et al., 2011; Driscoll, 2013; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Jobe & Gorin, 2012) that continuity in relationships is essential for engagement, for example: “It can take months to build up the confidence to speak more freely about their lives” (Grant et al., 2008, author description). Continuity was seen as enabling understanding and individualised care which was highly valued. For example:

“Individuals typically had one project worker assigned to them. […] This also meant that there was a close familiarity with and understanding of each person’s needs, preferences and home circumstances, the youngsters concerned readily acknowledging this as something they prized.” (Griffiths et al., 2012, author description)

By contrast, “having to repeat painful experiences to a stream of new workers” (Jobe & Gorin, 2012) was noted as particularly upsetting to young people (Chouliara et al., 2011; Grant et al., 2008; Houmoller et al., 2011; Jobe & Gorin, 2012). One author described the potential impact of negative experiences:

“After repeated experiences of having being ‘left’ by professionals some young people may develop feelings of resignation, which in turn may negatively affect their willingness to engage with professionals at a later stage.” (Houmoller et al., 2011, author description)

As such, several authors (Chouliara et al., 2011; Driscoll, 2013; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Jobe & Gorin, 2012; Munro et al., 2012) concluded that continuity is vital, and in one case ‘the most important factor’(Jobe & Gorin, 2012) for engendering trust and enabling successful engagement with young people.

Dependability was also seen as fundamental for engendering a trusting relationship with professionals. Young people in several studies described experiences of false promises and being let down by adults who they depended on (Collins & Barker, 2009; Fraser et al., 2009; Gaskell, 2010; Jobe & Gorin, 2012; Luke & Coyne, 2008). For example ‘I hate it when they say one thing and do another’(Fraser et al., 2009). Availability of professionals was another key component of trusting relationships expressed in six studies (Chouliara et al., 2011; Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Jobe & Gorin, 2012; Munro et al., 2012). For example:

“Many young people in our sample spoke about being unable to contact social workers during the referral process and this led to disillusionment and concern that social workers were not acting to protect them.” (Jobe & Gorin, 2012, author description)

By contrast, one author described that people affected by ACEs had a positive experience of having the option of contact between appointments or when on a waiting list: “because they felt reassured, less isolated, and cared for” (Chouliara et al., 2011). Another noted that “Services which ran an out-of-hours telephone service […] seemed particularly effective at being accessible and approachable” (Houmoller et al., 2011).

Delivering continuity appeared particularly important but difficult to achieve during the process of referral to social services (Jobe & Gorin, 2012). In another study (Houmoller et al., 2011) the authors considered the challenge of delivering services that were both accessible and offered continuity. They suggested that encouraging young people to:

“Feel a connection with and establish trust in the service organisation, rather than with just one individual […] would help young people manage staff turnover without feeling let down.” (Houmoller et al., 2011, author description)

Another key feature of services that was noted for fostering trust and engagement was offering a degree of flexibility and control to young people over how they were supported. Several studies (Gaskell, 2010; Grant et al., 2008; Houmoller et al., 2011; Jobe & Gorin, 2012; Matthews & Sykes, 2012; Munro et al., 2012) indicated the value for young people of being able to choose how to engage with services and how to manage the challenges in their lives. This could involve the mode in which services communicated with young people. For example, texting was acknowledged a convenient way of contacting young people and allowing opportunities to stay in touch on their own terms (Grant et al., 2008).

One young person described flexibility and control as important in response to the question ‘what makes a good social worker?’.

“When, they don’t tell you what to do. Like they listen to you. That they take things slowly and don’t rush you into doing stuff.” (Houmoller et al., 2011, young person and interviewer)

One author noted that young people valued knowing that they were able to withdraw from the service “at any time without feeling guilty” (Grant et al., 2008) and one young person described how they valued having choices about when, where and how discussions might take place: “If I didn’t want to talk, I’ll talk about general conversation […] if we’d go somewhere if I didn’t want to leave the car, we could stay in the car” (Houmoller et al., 2011).

One author noted how involvement in decisions, especially those relating to placements or termination of placements would be of particular significance to young people (Munro et al., 2012). There appeared to be a consensus across the studies that services that are “process driven and not designed with the needs of the service user at the forefront” (Jobe & Gorin, 2012) need to shift to an approach which, reflecting the first theme of this analysis, puts “professionals’ relationships with young people, and young people themselves, at the heart of the safeguarding agenda” (Jobe & Gorin, 2012).

Discussion

Summary and relevance to wider literature

Our qualitative synthesis responds to a key evidence gap identified by Bellis, Ashton, & et al. (2015) who describe the need for a better understanding of the types of support people affected by ACEs require and should receive. The need for both emotional and practical support has been previously identified in a qualitative evidence synthesis on the experiences and preferences of looked after children and young people (Dickson, Sutcliffe, & Gough, 2009). Our synthesis identifies and describes the nature of these needs across a broader range of ACEs.

We found that people affected by ACEs value emotional support from a trusted adult; they desire service providers who are empathetic, non-judgemental, and active listeners. Enabling peer support, for example through group therapy, is also valued. These findings corroborate evidence that points to the vital need for services to provide or enable the provision of emotional support in order to reduce the likelihood of depression in adults with at least one ACE (Brinker & Cheruvu, 2017).

In addition to emotional support, forms of practical support that services could offer include: information to help people understand and address their problems; help to manage everyday practical challenges such as engaging with the education or benefits systems; and respite from the responsibilities and problems they face, for example, through recreational activities. A randomised controlled trial (Gottlieb et al., 2016) found that in-person resource navigation for families with social needs significantly improved children’s overall health status and, alongside our results, speaks to the importance of personal practical support.

Widespread scepticism about services and service providers emphasises that services for people affected ACEs need to be sensitive to the challenges they have faced – which often include a loss of trust in key adults in their lives. Adequate time, flexibility and control over how and when they engage, are important factors for engendering young people’s trust in service providers. This resonates with wider literature which highlights the need for services to pay closer attention to the voices of those who they are aiming to support (Ungar, Liebenberg, & Ikeda, 2014), as well as the importance of bestowing children agency to increase the chances of positive responsiveness to treatment (Dodge, Murphy, O’Donnell, & Christopoulos, 2009).

Strengths and limitations

This systematic review of qualitative evidence brings together primary studies that have focused on the experiences of people who have accessed services on account of different ACEs. The synthesis highlights their shared needs and the ways in which services can be provided and delivered in a way which best supports them. This inclusive approach, focusing on young people who collectively have experienced household dysfunction, maltreatment, homelessness, and living in care – as well as adult survivors of sexual abuse – indicates that our findings may be generalisable across people who have experienced different types of ACEs in the UK. As such they may also be relevant to those in the UK who have experienced multiple ACEs. Although it should be noted that we did not identify any studies on parental incarceration or parental separation for inclusion in our synthesis. ACEs clearly exist on a dynamic spectrum, and are far from heterogenous, but our findings point to guiding principles which could be applied to inform practice.

Our approach for identifying primary studies from systematic reviews was, as noted above, both rigorous and efficient. However, while the studies included in the synthesis were selected for their quality and relevance to our own review the number of studies in our sample remains fairly small (n = 20). This approach necessarily excludes research which did not fit the original review authors’ inclusion criteria, which may have the unintended consequence of reproducing inbuilt biases in the evidence base. Another shortcoming, is that the most recent primary studies, published after the latest systematic reviews, would not have been identified.

Implications for policy and practice

Preventing and addressing ACEs are current policy priorities in Scotland and Wales. Public health authorities in both countries have established ACEs ‘Hubs’ (Adverse Childhood Experiences, NHS Health Scotland; and ACE Support Hub, Cymru Well Wales) to promote shared learning around ACEs research and practice. An inter-agency, holistic approach which advocates prevention and early help for those affected by ACEs are at the centre of both government’s agendas (Couper & Mackie, 2016; Scottish Government, 2017; Welsh Government, 2015, 2015, 2015).

UK policy regarding ACEs beyond the devolved nations appears to be more piecemeal. Co-operation between agencies to promote children’s well-being is a statutory obligation under section 10 of the Children Act 2004. While not consistently applied, inter agency working is evident in a range of policy initiatives which, at least, in part are in place to support people affected by ACEs. For example, NHS England’s Strategic Direction for Sexual Assault and Abuse Services: Lifelong care for victims and survivors: 2018–2023) recognizes the ‘devastating and lifelong consequences’ that sexual abuse can have on a victim’s life and espouses the need for a ‘seamless approach that recognizes individual needs and reduces fragmentation and gaps between services’ (p.10, 2018).

While it is important to acknowledge that people affected by ACEs are not a homogenous group, our findings suggest that service approaches which attempt to build up young people’s ability to trust and which nurture a sense of worth and belonging will meet the needs of The importance of collaborative, joined up working is highlighted, as is the need for continuity, when providing care for victims or survivors of trauma.

Another core priority in this strategy is ‘involving victims and survivors in the development and improvement of services’ (NHS England, 2018). Involving services users in the development of services is advocated in adversity and trauma–informed care (Sweeney, Filson, Kennedy, Collinson, & Gillard, 2018) and, in relation to people affected by ACEs, this could offer a mutually beneficial way to ensure services are appropriate while also empowering those affected by ACEs and teaching practical life skills.

Our synthesis found supportive relationships with peers or adults to be a key factor in overcoming problems. Innovations such as the £13 m Trusted Relationships Fund will support interventions that aim to strengthen the relationships between at-risk and vulnerable young people (10–17 years) and the adults who support them. Interventions will be aimed at those at risk of child sexual abuse or exploitation, criminal exploitation or relationship abuse and are currently in the process of being evaluated. Findings from these small-scale projects should be analyzed and, if appropriate, inform practice on a wider scale.

Directions for future research

We identified no studies focusing on parental incarceration or parental separation and there is clearly a lack of robust research in this area. Arguably the inclusion of parental separation as an adversity – in a time of considerably greater family diversity – is outmoded (Salter, 2018). Being from a single parent family does not necessarily constitute an adversity and in fact could be protective. Furthermore, the ACE framework has been criticised for contributing to a ‘failure to protect’ narrative which disproportionately affects mothers (Callaghan, 2019). Further research which adopts the ACE framework warrants a gendered approach and greater consideration of intersectional factors.

Only one study (Winter, 2010) explicitly stated the concurrent ACEs that participants were exposed to, and no studies specifically aimed to explore the experience of young people exposed to multiple ACEs. However, we could infer from a few studies that participants were exposed to co-occurring ACEs and as discussed in the introduction previous ACE research reveals that ACEs often cluster. Research is needed which explores how ACEs cluster or co-occur, and which examines interventions or services which target multiple ACEs.

Despite the obvious challenges in accessing relevant participants, research to understand the perceived service needs of young people who are not known to services would be a valuable addition to the ACEs landscape, especially in light of their so-called hidden nature, and the emotional and practical difficulties which young people may experience in accessing support.

None of our included studies aimed to look specifically at the role of known risk factors that exacerbate ACE experience, such as low socio-economic status (Walsh, McCartney, Smith, & Armour, 2019). In the broader review (Lester et al., 2019) which also looked at young people’s views on experiencing ACEs, financial hardship was shown to affect those living with parental mental illness and parental substance abuse but the role of poverty within ACE experience, and the service needs of young people living in poverty and affected by ACEs merits much closer scrutiny. UK research on child abuse and neglect has been criticised for having a lack of joined up thinking and action around poverty and child abuse and neglect (Bywaters et al., 2016; Gupta, 2017).

Research on ACEs could clearly also benefit from considering wider structural and socio-economic contexts. This is especially pertinent in light of the follow-up Marmot, Allen, Boyce, Goldblatt, and Morrison (2020) which bore stark conclusions about widening health inequalities in the UK, including increasing rates of homelessness and child poverty. Inevitably these pre-existing problems will be further exacerbated by the devastation wrought by COVID-19 pandemic (Bambra, Riordan, Ford, & Matthews, 2020) on young people and their families.

Our findings on the role of a single trusted adult for young people affected by ACES indicated that the attributes and approach of that adult is more important than their professional role. The potential to draw on adult support from a range of sources, including lay people, could be usefully explored in future research particularly given the current state of limited resources and cuts to services (Knapp et al., 2016). Alternative options for where, and specifically, who support could come from may be valuable.

Author’s contributions

The harvesting of primary studies to include in the review and quality appraisal process was undertaken by Katy Sutcliffe and Meena Khatwa. Data analysis and synthesis of data and writing up was carried out by all three authors. Sarah Lester and Katy Sutcliffe prepared the first draft of this paper, and all three authors revised and commented on versions of this paper during the editing and review process.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Table A1

List of included studies and quality and relevance appraisal.

No	Author(s) (Year) TitleACE population	Aims	Characteristics	Authors themes	Study quality
					Reliability	Relevance	Usefulness
1	Barn (2010) Care leavers and social capital: understanding and negotiating racial and ethnic identity.Looked after children	This study explored the impact of ethnicity upon social exclusion experienced by care leavers.	ACE population sample size: (26)Other participants*: noneAge: Not statedGender: m (16) f (20)Ethnicity: African-Caribbean (11) African (8) Asian (3) mixed parentage (10) white (4)SES: Not statedFamily Background: Not statedOther relevant details: None stated	• Presence of Social Capital • Absence of Social Capital	High	High	Gold
2	Bee et al. (2013) Defining quality of life in the children of parents with severe mental illness: A preliminary stakeholder-led model.Parental mental illness	This study used a bottom-up qualitative approach to develop a new stakeholder-led model of quality of life relevant to this population.	ACE population sample size: (6)Other participants*: parents (5) professionals (5)Age: 13–18 yearsGender: m (2) f (4)Ethnicity: not statedSES: not statedFamily Background: mothers with serious mental illness (4) (assume that means that 2 had fathers with serious mental illness)Other relevant details: recruited via a young carers’ service in the South West of England. Primary parental mental health diagnoses, as reported by the families comprised bipolar disorder (2), major depressive disorder (2), schizophrenia (1) and borderline personality disorder (1).	• Children’s emotional wellbeing • Children’s social wellbeing • Children’s economic wellbeing • Children’s family contexts and experiences	High	Medium	High
3	Brewer and Sparkes (2011) Young people living with parental bereavement: insights from an ethnographic study of a UK childhood bereavement service.Parental bereavement	The purpose of our study was to explore the experiences of young people bereaved of a parent, and investigate the factors that help them to live with their grief.	ACE population Sample size: (13)Other participants*: noneAge: 15 – 27 yearsGender: not statedEthnicity: white BritishSES: working class (3), middle class (10)Family Background: not statedOther relevant details: young people had been recently bereaved (4), experienced the death of a parent over ten years ago (9)	• Expressing emotion • Physical activity • Positive adult relationship • Area of competence • Friendship/social support • Transcendence • Fun and humour	High	High	Gold
4	Chouliara et al. (2011) Talking therapy services for adult survivors of childhood sexual abuse (CSA) in Scotland: Perspectives of service users and professionals.Survivors of child sexual abuse	This study aimed to elicit perceptions and experiences of talking therapy services for CSA survivors and professionals.	ACE population Sample size: survivors of CSA (13).Other participants*: professionals working in the field of CSA. (31)Age: 18 + yearsGender: f (13)Ethnicity: not statedSES: not statedFamily Background: not statedOther relevant details: Out of the 13 survivors (7) were accessing NHS services.	• Benefits from talking therapy • The therapeutic relationship • Safety to disclose • Breaking isolation • Enhancing self-worth and sense of self • Contextualising the abuse • Movement' toward recovery • Challenges of using/providing service • Difficulties of trauma-focused work • Contact between appointments • Continuity and consistency • Accessibility in acute episode • Hearing and managing disclosures • Dealing with child protection issues • Resource availability and service accessibility	High	High	Gold
5	Collins and Barker (2009) Psychological Help-Seeking in Homeless Adolescents.Homeless Adolescents	This qualitative study aimed to examine homeless young people’s views about seeking psychological help for their problems.	ACE population Sample size: (16)Age: 17–21Gender: m (9) f (9)Ethnicity: Black African (8), White British (2) Black British African (2), Black British Asian (2) Black British (1), Black Caribbean (1)SES: All homeless.Family Background: not statedOther relevant details: None was employed; (3) expressed an intention to enrol in further education.	• Why I need help: Domestic conflict, Psychological distress, Practical needs • Why I would seek help: Help gets you through distressing times, Help produces practical results • Why I wouldn't seek help: Asking for help is difficult and exposes you, Experience of betrayal, Beliefs antagonistic to seeking help • The Kind of help I want: Effective, Caring, Trustworthy, Understanding/ Empathic Genuine, Containing	High	High	Gold
6	Driscoll (2013) Supporting care leavers to fulfil their educational aspirations: Resilience, relationships and resistance to help.Care leavers	This study exploresthe significance of supportive relationships in enabling this group of young people to make decisions about their future and encouraging them to overcome setbacks in educational attainment	ACE population Sample size: 7Age: 16–20Gender: m (4) f (3)Ethnicity: white BritishSES: not statedFamily Background:foster care (4)with boyfriend (1)in own flat (1)in supported lodgings (1)Other relevant details: not stated	• If you knew my mum, that would be a funny question: birth families • I’ve got my own mentor, that’s me: mistrust and self-reliance • My carer kept me going: supportive relationships • Education and ‘turning points	High	High	Gold
7	Fraser et al. (2009) Exploring the Impact of Parental Drug/Alcohol Problems on Children and Parents in a Midlands County in 2005/06.Parental drug/alcohol misuse	This study explores the views of parents/carers and children and young people about the impact of parental substance use and implications for services.	ACE population Sample size: (8)Other participants*: (25) parentsAge: 4–14Gender: m (4) f (4)Ethnicity: white BritishSES: not statedFamily Background: All but one were children of (in most cases former) alcohol users. Living with parent(s) in family home (6), living in foster/residential care (2) Participants belonged to sibling groups (5) (two boys and a girl from 1 family and 2 sisters in local authority care)Other relevant details: Children were living with parents in (3) families, (3) of them being supervised by social services. In addition, children in a further (4) families were currently, and children in another (3) families had previously been, on the Child Protection Register. (3) children had been returned to their parents after periods in foster care. Various degrees of continuing drug use.	• Impact on family life • Experience of support • Origins and impact on family life	High	High	Gold
8	Gaskell (2010) If the social worker had called at least it would show they cared”. Young care leaver’s perspectives on the importance of care.Care leavers	This study aims to explore young care leavers’ experiences of care. Through this, the extent to which feelings of care shape self-esteem and a sense of self will be explored.	ACE population Sample size: (10)Age: 16–21Gender: m (3) f (7)Ethnicity: Black British (5) Black British (3) White British (2)SES: Not statedFamily Background: Not statedOther relevant details The group that had experienced both residential and foster care placements and all participants had entered the care system for the first time before the age of 11 years (8). All of the young people interviewed had multiple experiences of care placements.	• Inclusion in decision-making, the trust of a consistent adult and stability of services.	High	High	Gold
9	Grant et al. (2008) Young people supporting parents with mental health problems: Experiences of assessment and support.Young people supporting parents with mental health problems	In this study, we reflect on what can be done to identify, assess and support young people looking after parents with mental health problems.	ACE population Sample size: (10)Age: 11–16Gender: m (3) f (7)Ethnicity: not statedSES: not statedFamily Background: not statedOther relevant details: not stated	• Family-centred work: recognising interdependencies • Multiple caregiving demands • Mediating family conflicts • Help for the looked after person • Building and valuing relations of trust • Attention to pacing • Absolute trust in project workers • One-to-one work • Dependability and consistency • Continuity of relationships • Problem-solving • Like surrogate parents • Laid back and fun • Feeling in control • Group work • Forming friendships • We’re in this together • Respite • Outside recognition	Medium	High	High
10	Griffiths et al. (2012) Living with parents with obsessive—Compulsive disorder: Children’s lives and experiences.Living with Parents who have OCD	This study aimed to explore the experiences of young people with a parent with OCD, including the impact of parental OCD and their understanding of it.	ACE population Sample size: (10)Age: 13–19Gender: m (5) f (5)Ethnicity: British, British-Indian, and Greek-Cypriot backgrounds.SES: employed (3), unemployed due to ill health (3), retired (1)Family Background: pairs of siblings were included in the sample (3). All the young people lived with one biological parent with OCDOther relevant details: mothers (6) and father (1) were aged 40–56 years, a diagnosis of OCD from a mental health professional (6), self-diagnosed and had not had contact with statutory services (1).	• Control and boundaries • Telling: embarrassment and pride • Do I have OCD? • Getting the right help for me	High	High	Gold
11	Houmoller et al. (2011) Juggling Harms: Coping with Parental Substance Misuse.Parental substance misuse	A detailed exploration of young people’s experiences of family life over time, as changing contexts can have dramatic effects on young people’s coping capacities.	ACE population Sample size: (50) Other participants*: (11) parents/carers; professionals (4) service providers (17)Age: 10–18Gender: m (20) f (30)Ethnicity: not statedSES: not statedFamily Background: not statedOther relevant details: Almost half of the young people were affected by mother’s substance misuse, (11) were affected by both parents’ use and (13) of the young people were affected by father’s use only. (2) young people were affected by their grandparents’ (primary carer). Parents were using drugs, primarily heroin, crack and cocaine (17), alcohol (25) or both (8), parents that had died (2).	• Caring for family • Normalcy and social harm. • What we mean by social harms are the harms done to relationships • Identity formation and experiences outside of the family	High	High	Gold
12	Jobe and Gorin (2012) If kids don’t feel safe they don’t do anything’: young people’s views on seeking and receiving help from Children’s Social Care Services in England.Young people and experiences of maltreatment	This study explores young people's experiences of help seeking and their experiences of receiving help for maltreatment through statutory agencies.	ACE population Sample size: (24)Age: 11–14Gender: m (14) f (10)Ethnicity: white British (18) British-Asian (1) unaccompanied asylum-seeking children originally from Afghanistan (3) and Eritrea (2).SES: not statedFamily Background: not statedOther relevant details: Young people were recruited from different local authority areas (6).Taken into local authority care as a result of their referral (16). Others had social care intervention in their lives for short periods of time. Young people who had come into contact with Social Care Services in between the ages of 11 and 17 (18)Young people who had social care intervention from an early age (6)	• Importance of trusting, consistent relationship with social worker in making it more likely that a young person will disclose/ engage with services • Disclosure as a process, which requires feeling safe and being self-confident, alongside a trusting relationship with professional	High	High	Gold
13	Luke and Coyne (2008) Fostering self-esteem: Exploring adult recollections on the influence of foster parents.Young people in foster care	This study explores the ways in which foster parents had influenced the self‐esteem of a sample of five adults with differing foster care experiences.	ACE population Sample size: (5)Age: 18–46Gender: m (4) f (1)Ethnicity: White BritishSES: Not statedFamily Background: Not statedOther relevant details: Not stated	• Self-esteem when Entering Care • General Support/Attachment • Domain-Specific Support • Normality and Inclusion.	High	High	Gold
14	Madigan et al. (2013) Feeling the same or feeling different? An analysis of the experiences of young people in foster care.Young people in foster care	Interviews were carried out with nine 12–16-year-olds currently residing in foster care to explore their representations of ‘feeling the same or feeling different’.	ACE population Sample size: (9)Age: 12–16Gender: m (5) f (4)Ethnicity: not statedSES: not statedFamily Background:Other relevant details: Not stated	• If they know I’m in care • What the hell can they say to me • They alienate you. • People expect you to deal with it, that you’re different • Noticing differences	High	High	Gold
15	Matthews and Sykes (2012) Exploring health priorities for young people leaving care.Young people leaving care	The aim of this study was to explore the health priorities of young people leaving care. Nine young people were interviewed (aged 16–21 years) from two local authorities in England using an interpretive phenomenological approach.	ACE population Sample size: (9)Age: 16–21Gender: m (3) f (6)Ethnicity: not statedSES: not statedFamily Background: young people were currently in care (3) Had left care (6)Other relevant details: Not stated	• How Participants Viewed the term Health • Health behaviours • Motivation • Health as the absence of disease • Health Priorities and Health Needs • Health Advice and Support • Transition Out of Care	High	High	Gold
16	McMurray et al. (2011) Shards of the old looking glass: Restoring the significance of identity in promoting positive outcomes for looked-after children.Looked after children	This study looked at analysis of semi-structured interviews with 13 young people and their social workers.	ACE population Sample size: (13)Age: 12–16Gender: m (6) f (7)Ethnicity: not statedSES: not statedFamily Background: young people lived in residential care (6), with at least one birth parent (6) in foster care (1).Other relevant details: Not stated	• Identity shaped by family and social relationships • Presented identity as a protective mechanism not the real them • Rejection of identity that may lead to social stigmatization • Identity on standby	High	High	Gold
17	Montgomery et al. (2015) Feminist narrative study of the maternity care experiences of women who were sexually abused in childhood.Women survivors of child sexual abuse	To inform practice by exploring the impact that childhood sexual abuse has on the maternity care experiences of adult women.	ACE population Sample size: (9)Age: 28–52Gender: all femaleEthnicity: white BritishSES: ranged from those not in employment to professional women.Family Background: not statedOther relevant details: Not stated	• The women's narrative of self • Women's narrative of relationship • Women's narrative of context and the childbirth journey • The concept of ‘silence’ linked findings from interviews with women and healthcare professionals • The review of maternity care records	High	High	Gold
18	Munro et al. (2012) Evaluation of the staying put: 18+ family placement programme: Final report.Young people and foster care	Evaluation to assess the effectiveness and impact of ‘staying put’ pilot. It is targeted at young people who have 'established familial relationships' with their foster carers and offers this group the opportunity to remain with their carers until they reach the age of 21.	ACE population Sample size: (31)Age: 18–21Gender: m (20) f (16)Ethnicity: not statedSES: not statedFamily Background: Young people stayed put (21) Who did not stay (11) Where young people opted out of staying put (5) Cases where foster carers were not willing or able to accommodate young people once reaching legal adulthood (‘foster care opt out’) (4) local authority did not allow young person to remain in foster placement post 18 (2)Other relevant details: Not stated	• Staying Put Models of Delivery • Staying put or leaving care? Factors influencing the decision-making process • Staying put: contributing to providing young people with a secure base and nurturing attachments? • Experiences and impact of staying put	High	High	Gold
19	Saha et al. (2011) A narrative exploration of the sense of self of women recovering from childhood sexual abuse.Women recovering from child sexual abuse	To explore how the sense of self evolves through the recovery process after intensive therapy that focuses on issues pertaining to childhood sexual abuse (CSA).	ACE population Sample size:(4)Age: 34 to 61Gender: female onlyEthnicity: white BritishSES: educational levels ranged from leaving school at the age of 15 to obtaining a higher degree in education. Participants were employed (3) housewife. (1)Family Background: divorced (2) married (1) single (1) Older participants had grandchildren (2).Other relevant details: not stated	• Mental distress related to their childhood sexual trauma • Avoidance as a means to cope • Feelings of shame and guilt • Insignificance and undeserving • Unrealistic demands on self • Positive self-understanding after the group intervention programme	High	High	Gold
20	Winter (2010) The perspectives of young children in care about their circumstances and implications for social work practice.Young people in care.	The aims of the study were to explore the perspectives of young children in care about their circumstances and implications for social work practice.	ACE population Sample size: (10)Age: 4–7Gender: m (9) f (5)Ethnicity: not statedSES: not statedFamily Background: not statedOther relevant details: not stated	• Removal from home and loss of connections • Unresolved feelings • Not being listened to	High	High	Gold

Data from other participants was not included in the evidence synthesis.

Set	Searches
1	((divorce* and (parent* or child* or family or families)) or (parent* adj2 separat*) or (marital adj2 separation*) or (family adj2 breakdown) or (family adj2 breakup) or (family adj2 separation) or (marital adj2 break*) or (marriage adj2 break*)).ti,ab
2	Divorce/
3	1 or 2
4	(“parentally bereaved” or “parental bereavement” or “Parental death” or “bereaved children” or “parental loss” or “loss of a parent” or “childhood bereavement” or (children* adj grief) or (grieving adj child*) or ((parent* or mother* or father* or carer* or caregiver*) adj3 death)).ti,ab
5	(parental death/ or maternal death/) not (infant death/ or pregnancy/ or “cause of death”/ or perinatal death/ or exp “abortion, induced”/)
6	4 or 5
7	exp mental disorders/ and “Parent-Child relations”/
8	((parent* or mother* or father* or carer? or caregiver?) adj3 “mental health” adj (problem* or condition* or disorder* or illness* or difficult*)).ti,ab.
9	((parent* or mother* or father* or carer? or caregiver?) adj3 (mental* adj ill*)).ti,ab
10	((parent* or mother* or father* or carer? or caregiver?) adj3 (depressi* or anxiety) adj3 (clinical or severe or major or chronic* or illness* or condition* or disorder* or difficult*)).ti,ab.
11	((parent* or mother* or father* or carer? or caregiver?) adj3 depression).ti,ab.
12	((parent* or mother* or father* or carer? or caregiver?) adj3 (suicidal or suicide)).ti,ab.
13	((parent* or mother* or father* or carer or caregiver) adj3 (mental* adj disorder*)).ti,ab.
14	((parent* or mother* or father* or carer or caregiver) adj3 (psychiatric or psychologic*) adj3 (illness* or condition* or disorder* or difficult*)).ti,ab
15	7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
16	((parent* or mother* or father* or carer* or caregiver* or sibling* or “family member” or brother* or sister*) adj3 (incarcerat* or prison* or “imprisoned” or “imprisonment” or jail* or “penitatiary” or criminal* or “detention” or “probatation” or “parole” or “young offender” or “young offenders”)).ti,ab.
17	(“children of” adj2 prisoners).ti,ab.
18	((parent* or mother* or father* or carer* or caregiver* or sibling* or “family member” or brother* or sister*) adj2 (criminal* adj1 convict*)).ti,ab.
19	(Parent-child relations/ or child welfare/) and (Prisoners/ or Prisons/)
20	16 or 17 or 18 or 19
21	((parent* or mother* or father* or carer? or caregiver?) adj3 (substance? or drug? or drinking or alcohol* or solvent? or medication?) adj2 (“use” or abus* or misuse* or addict* or disorder* or dependen*)).ti,ab.
22	((parent* or mother* or father* or carer? or caregiver?) adj3 (alcoholism or alcoholic* or “heavy drinking” or addicts or “heavy drinkers” or “substance related” or “substance affected” or (drinking adj1 problem*))).ti,ab.
23	exp Substance-Related Disorders/ and Parent-Child relations/
24	21 or 22 or 23
25	(“Domestic violence” or “intimate partner violence” or (“IPV” not (vaccin* or ventilat*)) or “intimate partner abuse” or (battered adj3 (mother* or father* or spouse or partner)) or “domestic abuse” or “partner abuse” or (family adj2 violen*) or (families adj2 violen*)).ti,ab.
26	domestic violence/ or spouse abuse/ or intimate partner violence/
27	25 or 26
28	(((Sexual or physical* or verbal* or emotional* or psychologic*) adj2 (Abus* or assault*)) or incest* or “sexual violence” or ((rape or raped or violence) adj4 (home or family or parent* or families or homes or household?))).ti,ab.
29	Exposure to Violence/ or child abuse, sexual/ or physical abuse/
30	(abus* or assault*).ti,ab.
31	(((Ill adj treat*) or “Ill treatment” or maltreat* or mistreat* or “Neglect” or “cruelty” or “cruel” or abus* or assault*) adj3 (“offspring” or “young people” or children* or “childhood” or “child” or “boys” or “girls” or adolescen* or youth* or “young person” or teen* or preadolescen* or “early life”)).ti,ab.
32	maternal deprivation/ or Paternal deprivation/
33	(victim* adj2 (“home” or “homes” or “family” or “families” or “household” or “households”)).ti,ab.
34	Child Abuse/
35	“Child of Impaired Parents”/ or “Child, Foster”/ or “Child, Orphaned”/ or “Child, Adopted”/ or Homeless Youth/
36	(homeless* adj3 (“young people” or children* or childhood or child or boys or girls or adolescen* or youth* or “young person*” or teen*)).ti,ab.
37	((“Looked after” or foster* or “adoptive” or “in care”) adj1 (“young people” or children* or childhood or child or boys or girls or adolescen* or youth* or “young person*” or teen*)).ti,ab.
38	(((“moving” adj1 “care”) or (“leaving” adj1 “care”)) and (“young people” or children* or childhood or child or boys or girls or adolescen* or youth* or “young person” or teen*)).ti,ab.
39	“Foster Home Care”/
40	(“care leaver?” or “residential child*” or (“child welfare” adj2 (service* or centre or centres or center or centers)) or (“child protection” adj2 (service* or center or centers or centre or centres))).ti,ab.
41	((“living in care” or “kinship care” or “foster care” or “adoption care” or “group home” or “group homes” or “out of home placement” or “out of home care” or “child placement” or “local authority care” or “state care” or “alternative care” or “kith and kin care” or “kinship care”) and (“young people” or children* or childhood or child or boys or girls or adolescen* or youth* or “young person” or teen*)).ti,ab.
42	adult survivors of child abuse/ or Adult Survivors of Child Adverse Events/
43	child/ or “child, preschool”/ or adolescent/
44	(offspring or “young people” or children* or childhood or child or boys or girls or adolescen* or youth* or “young person” or teen* or juvenile* or preadolescen* or “early life”).ti,ab
45	43 or 44
46	“Caregivers”/ or parents/ or parenting/ or fathers/ or mothers/ or exp “Parent-Child Relations”/ or exp “Nuclear Family”/ or “Family”/ or exp “Family Relations”/ or exp “Grandparents”/ or exp “Single-Parent Family”/
47	(“Parent” or “parents” or “mother” or “mothers” or “father” or “fathers” or “home” or “homes” or “household” or “households” or “family” or “primary carer” or “foster carer” or “guardian” or “guardians” or “grandparent” or “grandparents” or “relatives” or maternal* or paternal* or sibling* or grandfather* or grandmother* or caregiver* or carer? or “families”).ti,ab.
48	46 or 47
49	((child* or “young people*” or adolesc*) and (abus* or neglect)).jw.
50	(abus* or neglect).jw.
51	(“Stressful childhood experiences” or “adverse childhood events” or “adverse childhood experiences” or “traumatic childhood experiences” or “Stressful childhood experience” or “adverse childhood event” or “adverse childhood experience” or “traumatic childhood experience” or “adverse home environment” or “adverse home environments” or “adverse family environment” or “adverse family environments” or “stressful home environment” or “stressful home environments” or “stressful family environment” or “stressful family environments”).ti,ab.
52	(((“synthesis” or “systematic”) and (“evidence” or “research” or “review”)) or (“review” and (integrat* or critical* or “mapping” or “comprehensive” or “evidence” or “research” or “literature”))).ti. or ((systematic adj2 review*) or (“meta-analysis” or “Review articles” or “systematic review*” or “Overview of reviews” or “Review of Reviews”) or (“data synthesis” or “evidence synthesis” or “metasynthesis” or “meta-synthesis” or “narrative synthesis” or “qualitative synthesis” or “quantitative synthesis” or “realist synthesis” or “research synthesis” or “synthesis of evidence” or “thematic synthesis” or “systematic map*” or “metaanaly*” or “meta-analy*” or “systematic overview*” or “systematic review*” or “systematically review*” or “bibliographic search” or “database search” or “electronic search” or “handsearch*” or “hand search*” or “keyword search” or “literature search” or “search term*” or “literature review” or “overview of reviews” or “review literature” or “reviewed the literature” or “reviews studies” or “scoping stud*” or “overview study” or “meta-ethnograph*” or “meta-epidemiological” or “data extraction” or “meta-regression” or “narrative review” or “art review” or “scoping review” or “iterative review” or “meta-summary”)).ti,ab.
53	30 and 45 and 48
54	3 or 6 or 15 or 20 or 24 or 27 or 28 or 29 or 32 or 33 or 50
55	45 and 54
56	31 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 49 or 51 or 53
57	55 or 56
58	limit 57 to systematic reviews
59	52 and 57
60	58 or 59
61	60 not (animals/ not (animals/ and humans/))
62	limit 61 to yr=“2007 -Current”
63	limit 62 to english