Routine Enquiry about Adversity in Childhood (REACh) programme

The REACh Model

REACh aims to raise awareness amongst professionals and the public about long term outcomes of childhood adversity and trauma. This is achieved by establishing and supporting organisational practice and culture change by embedding REACh within every appropriate assessment.

REACh involves, as part of the model of delivery, one or two-day training on why, when and how to enquire safely and sensitively, alongside organisational support, helping teams to navigate potential risks and challenges and to ensure appropriate staff support is in place.

The model has five key elements.

Stage one is a co-produced audit and evaluation of an organisations readiness to engage in routine enquiry. This helps to identify any potential systemic barriers and supports organisational buy-in.

Stage two involves consideration of change management processes and a review or design of an organisation’s specific systems and processes required to support effective and safe enquiry.

Stage three is the delivery of REACh training, which is tailored to the organisation’s specific needs, in terms of content and delivery methods.

During stage four, the REACh team offer time-limited follow-up support to the organisation, including consultation and supervision for staff and leadership teams, to ensure effective implementation.

Finally, in stage five, the team support the organisation to evaluate the implementation of REACh, to assess practice change and the impact on their service and service-users.

Evidence Supporting the REACh – Routine Enquiry about Adversity in Childhood Model

In evaluating the initial work with Lancashire First Episode Psychosis (FEP) service, the findings of a practice change audit revealed the importance of follow up support for front line staff and for supervisors and team leaders in the six months post training. A review of the evidence relating to the effectiveness of psychosocial interventions training suggests that practice change is not sustained without ongoing high-quality supervision and support for workers once they return to the day job (Brooker and Brabban, 2004). This review also revealed that other enablers of sustainable practice change are a whole team approach, management buy in and support for the changes in practice and extra time to conduct the intervention.

In a study by Toner, Daiches and Larkin (2013), psychological therapists working in FEP services in England were interviewed about their attitudes and experience of asking service users about abuse and trauma, as previous research had indicated that professionals are reluctant to ask (Felitti et al 1998; Read et al 2007). This study revealed that therapists that did ask about abuse and trauma routinely, tended to work in services that had a service culture that supported their practice of routine enquiry, there was a clear process to follow within the service and the therapist held a psychosocial model of psychosis. In other words, they saw the relevance of adverse life experiences to the emergence and experience of psychosis. The authors concluded that for psychological therapists, understanding ‘why ask? was fundamental.

In 2014, evaluation of the experiences and insights of staff trained in Routine Enquiry about Adversity in Childhood revealed a number of positive impacts on professional practice and client outcomes (Pearce et al, 2019). For instance, Routine Enquiry training inspired practitioners to develop a trauma-informed understanding of clients experiences, resulting in clinical practice changes, which, in turn, facilitated more lasting change for clients. It was found that enquiries encouraged clients to make links between their past and their present situation, enabling them to accurately identify the right support for them, at the right time. The research findings also suggested that not all clients required, or wanted referrals for psychological or other practical support in relation to their disclosure. In the majority of cases, therapeutic conversations with practitioners seemed to be sufficient to encourage meaningful change.

In 2015, an independent evaluation of the Routine Enquiry about Adversity in Childhood programme (Real Life Research, 2015) found that Routine Enquiry training equips practitioners with the knowledge and tools to conduct routine enquiry effectively with the people they support. All practitioners who attended the training reported that it was useful, enjoyable and increased their knowledge and awareness of childhood adversity and trauma, including its widespread impacts. Routine Enquiry was found to initiate earlier intervention, as a result of speedier disclosures. Importantly, practitioners reported no issues with implementing Routine Enquiry in their practice and reported no increase in service need following the enquiries made. Participants and managers felt that they were able to create, with the individual, a more appropriate intervention plan if they have enquired about previous experiences, dealing with the root cause of presenting issues rather than the ‘symptom.

Another evaluation in 2016, qualitatively explored the impact of Routine Enquiry about Adversity in Childhood on parents accessing an early help family support team (Simpson-Adkins et al, submitted manuscript). Results demonstrated that all parents agreed to engage in enquiries. Although the process of disclosure was emotive, parents post-disclosure reflections resulted in a process in which they re-evaluated their parental goals, roles and priorities. This re-evaluation appeared to initiate a drive to parent differently, propelled by their desire to give their child a better start in life. These results demonstrated that, without any post Routine Enquiry intervention, parents appeared to engage in a self-determined process of post-disclosure behaviour change, alongside a number of positive impacts, such as increased mentalizing capacity (Allen and Fonagy, 2006) and experiences comparable to post-traumatic growth (Tedeschi and Calhoun, 2004). These impacts resulted in reports of improved relationships between parents and their children.

In 2018, an evaluation of our work with GPs in Lancashire was completed by Public Health Wales. This work was funded by NHS England and demonstrates the feasibility and acceptability of REACh within the primary care context and offers the conclusion, ’This proof of concept report provides initial support for the acceptability of ACE enquiry in general practice among both patients and practitioners, who identified it as a means of improving the patient-practitioner relationship and better understanding wider determinants for health and wellbeing.

Warren Larkin Associates are currently working with GPs in Macedonia in collaboration with UNICEF and working with NHS Health Scotland in a trial of REACh in a number of their Deep End practices. A recent Editorial in the British Journal of General Practice outlines the work we are doing to implement REACh and ACE enquiry in primary care.

In 2020, The REACh training was delivered to the entire Better Start Health Visiting service in Blackpool, with refresher sessions being provided at planned intervals and regular clinical skills sessions being provided in-house. Routine Enquiry about ACEs became standard practice for all HVs at the antenatal visit in late 2018/early 2019. The evaluation was conducted by the Centre for Early Child Development research and evaluation team. Telephone interviews were conducted with 59 participants (equivalent to a 64% response rate) between March 2019 and March 2020.

Participants found the enquiry appropriate and useful, and that their Health Visitor succeeded in ensuring they felt safe and listened to when disclosing information about their ACEs. Both quantitative and qualitative analysis suggested that caregivers found the ACE enquiry useful and felt they were asked in an appropriate manner. Participants demonstrated that they understood the importance and relevance of the enquiry regardless of having experienced ACEs or not. The enquiry appeared to succeed in increasing their awareness of ACEs and provided caregivers with a space to open up to their Health Visitor regarding ACEs. It appeared to positively influence caregiver’s motivation to ensure their own child/children do not experience ACEs, subsequently contributing to the aim of mitigating the impact of intergenerational ACEs within families. It was clear that participants appreciated that the enquiry and that it provided them with an opportunity to talk about their ACEs. This accompanied participants expressing appreciation for knowing there was someone there for them who cared and would provide support for present and future issues. The exercise of opening up a conversation regarding ACEs appeared to help normalise the topic and facilitated caregivers feeling less judgment surrounding ACEs. The report can be referred to at content/uploads/2021/03/HV_ACE_Report_240321.pdf

REACh is currently being implemented and evaluated in a system wide, multi-agency implementation across the county of Nottinghamshire. This Public Health led initiative is the largest roll out of targeted and routine ACE enquiry ever attempted in the UK and is being evaluated by the World Health Organisation Collaborating Centre for Violence Reduction at Liverpool John Moores University. The final evaluation is being conducted and will be published in the spring/ summer of 2022.

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(REACh) Programme

REACh aims to raise awareness about long term outcomes of childhood adversity and trauma