adverse childhood experiences: strategies for...
TRANSCRIPT
Adverse Childhood Experiences:
Strategies for Prevention
Dr. Regina Olasin, Care for the Homeless NYCKaren Hudson PhD, MSW ,LSW, Children’s Hospital of
PhiladelphiaStephanie Krauthamer Ewing ,PhD., MPH Drexel
University Sarah Kimball, MPH, Bronxworks
NHCH Learning LabMay 25,2019
Objectives
1. To review and detail the Adverse Childhood Event ( ACE ) study and lifespan health impact of adverse childhood events.
2. To understand Trauma Informed Care and the inclusion of the Social Determinants of Health as critical components in effective care coordination.
3. To present front line interventions addressing parenting skills and school attendance.
4. To use the Laboratory context a working model for how to best address this health paradigm optimally for the homeless and unstably housed population.
Disclosures
We have no financial disclosures
Housing as Healthcare is not yet an FDA approved
prescription for the condition of homelessness
There is no trust more sacred than the one the world holds with children. There is no duty more important
than ensuring that their rights are respected, that their welfare is protected, that their lives are free from
fear and want and that they grow up in peace.
Kofi A. Annan
Brother Son
15 y/oAsthma
Depression“anger issues”
Grandmother
43 y/o
MDD
anemia
Morbid obesity
Raynaud's Dse
Mom
DaughterMDD-recurrent
PTSD
Victim of childhood sexual
abuse
LDAsthma/GERD/anemia
Baby
21 mo.
Apnea
RSVMental illness in member
of household
Baby
5 mo.
32 week VLBW
Sub cut hemangioma
Heart murmur
Patient so so psychotic. just came in. Has hx of everything. Adopted by animals at two months. Sexual abuse by brothers. She was derailing talking about not trusting medical or government. . And I asked her something can’t remember- her answer “ I like birds. I watch them and I write down what I see. “ Then she showed me her journal. And her “ words that mean lots of different things “ has zero education maybe 6th grade. Said she has “been in system since she was in the womb”. But her description of each bird was poetry. Truly. Just completely staggered me. I was so touched. I teared up and she looked at me for solid 20 seconds. I apologized and said her writing was lovely.
Access to artistic expression provides the only relief and chance for a moment engaged in something beautiful and not tragic for her.
The Text
“Toxic Stress Derails Healthy Development”
https://www.youtube.com/watch?v=rVwFkcOZHJw
Early neurotoxicity—plasticity and repair
An infant’s brain can produce two
million new synapses every second-a
warp-speed neural spider web that
sets the parameters of a person’s
capacity to think, learn and process
emotion.
The ACE StudyThis 1998 study was a collaboration
between the Centers for Disease Control & Prevention (CDC) and Kaiser Permanente.
> 17,000 Kaiser patients 1992-95
Middle-class Americans
Landmark study that examined the health and social effects of adverse childhood experiences over the lifespan
Am J Prev Med 1998;14(4)
ACE Study Findings
Of the 17,000+ respondents…
More than 25% grew up in a household
with an alcoholic or drug user
25% had been beaten as children
Two-thirds had 1 adverse childhood event
1 in 6 people had four or more ACES
Source: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm
The A.C.E. Categories: Contribute to ACE Score
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Mother Treated Violently
Household Substance Abuse
Household Mental Illness
Parental Separation or Divorce
Incarcerated Household member
http://www.cdc.gov/ace/about.htm
ACE Scoring
One point is given for each type of trauma.
The higher the ACE score, the higher the risk of
health and social problems.
ACE score of ≥4 correlates with serious adverse
health outcomes and an increased risk for:
Chronic Obstructive Pulmonary Disease Increases 390%
Hepatitis 240%
Depression 460%
Suicide 1,220%
http://acestoohigh.com/got-your-ace-score/
Adverse Childhood Experiences Are Very Common
Percent reporting types of ACEs in original study:
Household exposures:
Alcohol abuse 23.5%
Mental illness 18.8%
Battered mother 12.5%
Drug abuse 4.9%
Criminal behavior 3.4%
Childhood Abuse:
Psychological 11.0%
Physical 30.1%
Sexual 19.9%
Emotional Health Among
Youth Experiencing Homelessness
Youth experiencing recent family homelessness are at
higher risk of suicidality than non-homeless peers
suggesting that homelessness is a marker of risk
Factors that impact emotional health are less impactful
among youth experiencing recent family homelessness
Interventions among homeless youth may need to
address social determinants of health such as stable
housing and adversity in addition to developmental
assets.
Barnes A J, Gilbertson J, Chatterjee D. Emotional Health Among Youth Experiencing Family Homelessness. Pediatrics
2018;141(4)e20171767
The ACE Pyramid
http://www.cdc.gov/ace/about.htm
• Early Death
• Disease, Disability & Social Problems
• Adoption of Health-risk Behaviors
• Social, Emotional & Cognitive Impairment
• Adverse Childhood Experiences
Effect of ACEs on Mortality
0
10
20
30
40
50
60
Pe
rce
nt
in A
ge
Gro
up
0 2 4
ACE Score
19-34
35-49
50-64
>=65
Age Group
ACES
determine the likelihood of the ten most common causes of
death in the United States.
Top 10 Risk Factors Are:
Smoking Severe Obesity
Physical inactivity Depression
Suicide attempt Alcoholism
Illicit drug use Injected drug use
50+ sexual partners h/o STDs
Clear dose-response relationship between
stressors causes adverse health outcomes up to
50 years later
Compared with people with no ACEs, those with 4 or more ACEs were…..
Twice as likely to smoke, have cancer or heart disease
7x as likely to be alcoholics
6x as likely to have had sex before age 15
12x more likely to have attempted suicide
Men with 6+ ACEs were 46x more likely to have injected drugs than men with no history of adverse childhood experience
Source: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm
Childhood Experiences /Chronic Depression
0
10
20
30
40
50
60
70
80
% W
ith
a L
ife
tim
e H
isto
ry o
f
De
pre
ss
ion
0 1 2 3 >=4
ACE Score
Women
Men
Childhood Experiences / Suicide
0
5
10
15
20
25
% A
ttem
pti
ng
Su
icid
e
ACE Score
12
0
3
4+
Untreated Adverse Early Childhood Events
Only Exacerbate Over Time
Source: Adverse Childhood Experiences (ACE) Study. Information available at http://www.cdc.gov/ace/index.htm
Types of Responses to Stress
Positive
Tolerable
Toxic
http://developingchild.harvard.edu/topics/science_of_early_childhood/toxic_stress_response/Toxic Stress: The Facts, Center on the Developing Child at Harvard University
Pediatrician Perspectives on Content of
Health Supervision
Most pediatricians say they discuss traditional topics with less
than 75% of parents of patients 0-9 months:
Immunizations (94%), nutrition (93%), sleeping positions (82%),
breastfeeding (70%)
Less frequently discussed are topics related to cognitive
development:
Reading to child (48%) & how child communicates (42%)
Least discussed are topics related to family & community
needs:
Social support (28%), financial needs (16%), violence in the community
(13%)
PSQ
Protective Factors for Resilience
National Scientific Council on the Developing Child. Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper #3. Cambridge, MA: National Scientific Council on the Developing Child, Center on the Developing Child at Harvard University; 2005. Available at www.developingchild.harvard.edu. Accessed January 17, 2014.
Safe, cohesive neighborhood
Basic needs met : Food, Housing, etc.
Safe home
Connection with a caring, stable adult
Access to healthcare and social services
Trauma Informed Care (TIC)
“Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors to rebuild a sense of control and empowerment.” (Hopper et al, 2010)
“Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” (SAMHAS)
What does Trauma Informed Care offer?
Improves desired outcomes
Supports victims of trauma recovery through:
Reducing re-traumatization in the medical home
Providing “corrective emotional experience” to change
paradigms of recollection
Decreases vicarious trauma or compassion fatigue
among providers
Tips for Practicing TIC
Use language the person recognizes
“Has your partner messed with your birth control?”
Meet the survivor “where they are”
If a person is not ready to talk, do not force the
conversation. Rather keep the door open for a later time.
Consider the person’s cultural context
Avoid making assumptions – just ask!
Tips for Practicing TIC
Recognize adaptive behaviors serve a purpose
Why is a person chronically miss morning appointments?
Is the morning the only time she can sleep? Does she have
a traumatic brain injury that prevents her from
remembering things?
Make adjustments to help that person succeed. Set
appointment times for the afternoon.
Include everyone in your agency
From receptionist to treatment staff
Provide trauma training to every employee
Overview
Offer support and validation
Communicate care and concern
Avoid passing judgement
Ask questions of the survivor
Find out if she is experiencing some kind of violence or coercion in her
life
Listen to what she has to say
Resist interrupting her
Make sure your body language is receptive
Offer information and assistance
Give her a resource card, a phone number, or a website
Refer her to an advocate (warm hand-off)
Tell her you are available to her in the future
Add Social
Determinant of
Health to In-patient
AND out patient
encounters to
facilitated optimal
care coordination.
Strive to introduce NORMALCY…
The Homeless Health Initiative
Family Care Curriculum (FCC): A Train-the-Trainer Parenting Support Model
For Families Experiencing Homelessness
National Health Care for the Homeless Conference
5/25/2019
SANDY SHELLER KAREN M. HUDSON
MA, ATR-BC, LPC PhD, MSW, LSW
STEPHANIE KRAUTHAMER EWING JOAN BLOCH JAMIE C SLAUGHTER-ACEY
Ph.D, MPH PhD, CRNP, FAAN PhD, MPH
Seeking to Build Stronger Families
“Past research has shown that for a child to escape the cycle of poverty & become a productive & healthy member of society it is essential that a child experience a nurturing relationship in which he or she is valued & communicated with.”
Kelly, J.F., Buchlman, K., & Calwell, K.
(2000). Training personnel to
promote quality parent-child
interaction in families who are
homeless, Topics in Early
Childhood Special
Education, 20(3), p.175.
Yet, we noticed that newly learned
parenting techniques were not always
carried out, especially when parents were
undergoing emotional stressors
such as living in shelter.
The Beginning…
We Found:
Mandated parenting programs were behaviorally oriented & not trauma-informed
Importance of culture not usually addressed
No consistency across agencies
Little support for parents and staff within agencies
Paucity of research studies demonstrating effectiveness
No follow-up support after parenting program
Lack of community building
Family Care Curriculum (FCC)
Developed in 2009: The best of our work from
the frontlines around parent & staff training
A six week parenting curriculum that addressed gaps in
parent training and team taught by diverse trainers
Encouraged a cultural paradigm shift within the agency
implementing FCC
Included & addresses the importance of culture when
parenting
Incorporated principles from DHS Parenting Collaborative
Goals that identified best practices
Received endorsement from City of Phila Officials & OSH
A Unique Form of Enhancing Parenting
FCC is a program designed to alter developmental
pathways of at-risk families
Purposed to enhance parent’s sensitivity &
responsiveness to their children
Builds parental reflective capacities
Uses an attachment-based perspective, a trauma-
informed lens, and tenets from social-learning theory
Emphasizes the role of culture in parenting
Incorporates principles of self-care
Is manualized, brief, affordable, easily implemented
Family Care Train-the-Trainer Curriculum
Six-Week Curriculum
Week 1 Creating the Framework-The Importance of Attachment & Culture
Week 2 Child Development
Week 3 Lessons From the Past
Week 4 Join the Club- We All Have Ghosts From Our Past
Week 5 Paradigm Shift-Learning New Skills
Week 6 Celebrating Next Steps
Implementation and Evaluation To Date
Since 2009, 200 providers from over 53 mostly
women and children shelters were trained in FCC
8 agencies have implemented FCC; others have
incorporated some of its principles
Multiple supportive conference calls and
refresher trainings
Consistent positive qualitative feedback from staff and parent focus groups and
questionnaires:
Strengths- Staff Report Strengths- Parent Report Challenges
• Across agencies, staff report
that moms are very excited
about FCC; some mothers
express that they wish it could
continue.
• Providers recognized the value
of FCC’s approach. Staff report
observing more positive
parental interactions with
children
• Staff also report increased
insight into their own
interactions with children and
with the families they serve.
• Staff report that feasibility of
training and implementation is
good- They are able to fit FCC
into the context of their own
agency
• Positive changes in
attitudes about
their children and
themselves as
parents
• More ability to be
available,
consistent and
nurturing with
their children
• Better
understanding of
child development
and alternate new
ways to provide
consequences and
discipline
• One agency
reported
challenges with
scheduling when
they tried to
implement it
twice/week,
instead of once.
• One agency
reported
challenges with
child care
• Agencies have
requested
adaptation for
special
populations such
as custodial
fathers, victims
of domestic
violence
Ongoing Research and Evaluation and Next Steps
Scholarship and write-up of work to date:
Sheller, S. L., Hudson, K. M., Bloch, J. R., Biddle, B., Ewing, E. S. K., & Slaughter-Acey, J. C. (2018). Family Care Curriculum: A Parenting Support Program for Families Experiencing Homelessness. Maternal and Child Health Journal, 22(9), 1247-1254.
Perlman, S., Sheller, S., Hudson, K. M., & Wilson, C. L. (2014). Parenting in the face of homelessness. In Supporting families experiencing homelessness (pp. 57-77). Springer, New York, NY.
Current work:
1. Analyzing some preliminary quantitative data on changes in constructs such as parental self-efficacy and parenting approaches
2. Working to enhance and improve the train-the-trainer manual and the program manual
3. Working to ensure that the content incorporates an intersectionality approach
4. Working to develop and implement a formal research pilot study as part of program enhancement and development in order to build an evidence base
Improving School
Attendance for Homeless
Children (ISAHC)Sarah Kimball, MPH
The School Attendance Problem
During the 2013-2014 school year in New York City, 34.3% of temporary housed K-12 students had “good attendance” compared to 73.5% of their permanently housed peers.
Good attendance is defined as attending school 90% or more of the time.
Inconsistent school attendance can result in delayed graduation or school drop-out, perpetuating the cycle of poverty.
Pappas. Liza. Not Reaching the Door: Homeless Students Face Many Hurdles on the Way to School, New York City Independent Budget Office, October 2016. Page
5. Accessed at http://www.ibo.nyc.ny.us/iboreports/not-reaching-the-door-homeless-students-face-many-hurdles-on-the-way-to-school.pdf
Pilot Intervention Funding
Robin Hood Foundation Grant
Funded started for 2018-2019 school year and will continue for 2019-2020
Gateway Housing
Coordinates overall intervention
Hired consultant to design intervention and program coordinator who
liaisons between the different shelters
Four New York City family shelters participating
BronxWorks – two sites
HELP USA – one site
Women in Need – one site
Pilot Intervention The ISAHC Model has four main interdependent
components
Team Approach
Shelter side staffed primarily by Client Care Coordinators (CCC)
DOE side staffed primarily by Family Assistants
Data Informed
Weekly attendance reports accessible through CARES
Additional school data brought in by DOE staff
Coordinator
New resource guiding the teams, supporting collaboration
Training
To increase the knowledge of CCCs around navigating the school system
To increase the ability of DOE staff to work effectively with families
Intervention
Site
Intervention
Site
Control
Site
Intervention
Site
Intervention
Site
Control
Site
Intervention
Site
Intervention
Site
Control
Site
Intervention
Site
Intervention
Site
Control
Site
“The solution of
adult problems
tomorrow
depends in large
measure upon the
way our children
grow up today”.
Margaret Mead
THANK YOU
Dr. Regina Olasin, FAAP,FACP
Care for the Homeless NYC
Karen Hudson PhD, MSW ,LSW,
Children’s Hospital of Philadelphia
Stephanie Krauthamer Ewing ,PhD., MPH
Drexel University
Sarah Kimball, MPH,
Bronxworks
Resource URLs
ACES
• TED Talk: https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime
• CDC: https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html
• Academy on Violence and Abuse: https://www.avahealth.org/resources/aces_best_practices/aces-best-practices.html
Evidence Based Treatment & Prevention
• NCTSN: https://www.nctsn.org/
• ISTSS: https://www.istss.org/
• Children’s Bureau: https://www.acf.hhs.gov/cb/programs
• SAMHSA: https://www.samhsa.gov/
• Maternal Depression: http://www.movingbeyonddepression.org/
Advocacy & Policy
• AAP: https://www.aap.org/en-us/Pages/Default.aspx
• APAs: https://www.apa.org/ & https://www.psychiatry.org/
• AACAP: https://www.aacap.org/
Additional Resource URLs: http://www.canarratives.org/