State data fuels the ACEs conversation in Iowa

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Most Iowans didn’t learn about the Centers for Disease Control’s ACE Study until early 2011. But in the three years since then, the state has completed two ACE surveys, one of them published, with a third survey underway and a fourth scheduled for 2015. Iowa has hosted three ACEs summits; two statewide summits in 2014 focus on ACEs in early childhood, and education and juvenile justice. And nearly every sector—including health care, education, social services and corrections—is busy answering the question: How do we integrate this knowledge into what we do?

“To this day, I can’t find out who knew to bring him here,” says Suzanne Mineck, president of the Mid Iowa Health Foundation, referring to physician Robert Anda, co-principal investigator of the CDC’s Adverse Childhood Experiences Study. Anda was invited to give the keynote at the state’s annual Early Childhood Iowa Congress in 2011.

“The ballroom was packed—maybe 300 people,” Mineck recalls. “After his presentation, a group of us walked out and looked at each other. We decided that what we’d heard was really important, and we needed to do something with it.”

Over the next few months, the ACE Study kept coming up in “water-cooler” conversations among people in Iowa’s health and child welfare communities. So the health foundation decided to bring two questions to a small group of state and community leaders: “Is this relevant to the work in our state? If the answer is ‘yes,’ what are we going to do about it?”

Fielding those questions were Sonni Vierling, state coordinator for the 1st Five Healthy Mental Development, a project of the Iowa Department of Public Health, and representatives from the Polk County Health Department, Orchard Place Child Guidance Center, United Way of Central Iowa, and Prevent Child Abuse Iowa.

“Data is what led the conversation from the beginning,” says Mineck. The CDC’s data plugged real science into what many on the front lines of health and social services already knew, but the numbers also begged the question: Does Iowa have the same incidence of childhood adversity?

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Iowa’s Department of Public Health was willing to include the ACE survey in the Behavioral Risk Factor Surveillance System (BRFSS) that all states use to measure rates of obesity, smoking, cancer, teen pregnancy and other health issues. But it would cost $24,000 to do the survey.

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One-way mirrors, monitors and a whole lot of training — how Parent-Child Interaction Therapy works

A typical setup for a PICT training, in which a counselor monitors interaction between parent and child.

A typical setup for a PICT training, in which a counselor monitors interaction between parent and child.

By Christie Renick

Carla Francis’ training session is fast-paced.

Francis, a therapist, sits in an observation room with two monitors in front of her; one displays her clients – a grandmotherly woman and a toddler (their names have been changed to protect their identity) — in the playroom next door, and through the other she sees her virtual trainer, psychologist Dawn Blacker, who observes from her office hundreds of miles north at the University of California, Davis.

Francis is wearing a headset, and every 45 seconds or so she gives the woman in the playroom instructions through a “bug“ in the woman’s ear.

“Good label praise, Mrs. Green,” Francis says. “Good reflection.” Francis is following protocol by verbally reaffirming Mrs. Green’s actions as the woman and the toddler play on the other side of the mirror.

Francis is being trained to deliver Parent-Child Interaction Therapy (PCIT) at Kedren Mental Health Center in Los Angeles’ West Adams neighborhood. Kedren serves mostly biological parents, some of whom are involved in the reunification process with dependency court, but it also serves foster parents and parents of children with speech delays or who are on the autism spectrum.

The toddler, Kiana, used to exhibit aggressive behavior, hitting her siblings and snatching toys away. Mrs. Green, her caregiver, didn’t know how to manage Kiana’s outbursts. Today Kiana is calm, making eye contact with Mrs. Green and handling the toys gently.

PCIT is part of a child maltreatment prevention program being rolled out across Los Angeles County through a partnership between the county’s Department of Mental Health and First 5 LA. As The Chronicle of Social Change reported in July, the goal is to train as many as 400 therapists in PCIT through this partnership.

Training for local PCIT therapists uses technology that allows a trainer, in this case Blacker, to see both the trainee, Francis, in her observation room and her clients, Mrs. Green and Kiana, in a playroom that his been outfitted with a one-way mirror so Francis can see in.

The yearlong training starts with an online course and culminates when a trainee completes two cases, meaning they work with two families and provide each with up to 20 therapy sessions. A trainer like Blacker oversees each of these sessions. This is Francis’ first case, and the 12th session with Mrs. Green and Kiana.

Last month, hundreds of professionals gathered at the University of California, Los Angeles for an annual PCIT conference. Researchers, therapists and

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Los Angeles bets big on Parent-Child Interaction Therapy to reduce adverse childhood experiences

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By Christie Renick

In June 2014, the Los Angeles County Board of Supervisors began implementing the recommendations made by the Blue Ribbon Commission on Child Protection, which calls for augmented child maltreatment prevention efforts.

While implementation of the commission’s many recommendations is a long-term venture, leaders are hoping that the rollout of a maltreatment prevention initiative may improve child safety in the short-term.

First 5 LA, a taxpayer-supported initiative that provides a variety of services to families with young children in Los Angeles County, is investing $20 million in child maltreatment prevention with a five-year therapist-training program known as Parent-Child Interaction Therapy (PCIT).

The goal is to train up to 400 PCIT practitioners through the state. First 5 LA’s PCIT grant is in partnership with the county’s Department of Mental Health, through which PCIT providers can access state-funded reimbursement for services.

PCIT emphasizes improving the quality of the parent-child relationship through one-on-one live coaching. During a PCIT session, a parent-child pair plays and interacts in a therapy room while the therapist watches through a one-way mirror and guides their interactions using a discrete earpiece worn by the parent. PCIT is typically delivered in a series of 12 to 14 sessions and is broken into two main parts, relationship enhancement and strategies to improve compliance.

In Los Angeles, PCIT is being made available to families at risk of becoming involved with the child welfare system, or who have open cases but are not currently in the process of having their parental rights terminated.

After linking a lack of prevention services with “an excessive number of referrals and investigations” and high caseloads in the county’s dependency court system, the Blue Ribbon Commission’s final report, issued in April, called on the county’s board of supervisors to direct the Department of Public Health and First 5 LA to jointly develop a comprehensive prevention plan.

By training hundreds of clinicians and therapists who will serve thousands of families in the county, this will be the largest PCIT initiative since its development in the early 1970s, a prospect that excites researchers close to the strategy.

“The prospect of prevention is very powerful because we’ve shown the parents, with PCIT…[they] can change and become positive, nurturing, sensitive parents who can set limits with their children in a safe and effective way,” said Cheryl McNeil, a professor of psychology at West Virginia University. “Prevention efforts with PCIT encourage parents to use highly positive parenting tools before they get into negative interactions with their children.”

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Children’s Resilience Initiative in Walla Walla, WA, draws spotlight to trauma-sensitive school

RRocksbannerIn Walla Walla, Washington, the journey to implement ACEs research has been akin to a wild ride on a transformer roller coaster that arbitrarily changes its careening turns, mountainous ascents, and hair-raising plunges. And sometimes the ride just screeches to a frustrating halt.

The odyssey began in October 2007, when Teri Barila, Walla Walla County Community Network coordinator, heard Dr. Robert Anda, co-investigator of the CDC’s Adverse Childhood Experiences Study (ACE Study), speak at a Washington State Family Policy Council (FPC) event.

Without a doubt, he said, childhood trauma is the nation’s No. 1 public health problem. The ACE Study – the largest public health study you never heard of — shows that childhood trauma is very, very common. (ACE surveys in 22 states now echo the results.) And this childhood adversity causes violence, including family violence, as well as the adult onset of chronic disease and mental illness.

The Family Policy Council was the umbrella organization for 42 community networks across the state that were addressing local issues such as youth substance abuse, school drop-out rates and teen pregnancy. Anda implored the coordinators to “get something started” in their own communities because he was getting little traction on a national level.

Barila returned to Walla Walla fired up. The city, with a population of 32,000, has three colleges, a robust agricultural community, including a newly flourishing wine industry, and a revitalized downtown. But one out of four of its children live in poverty, 65% of its residents have not attended college, and gangs and drugs are common. Barila was determined to educate the community about the dire and costly consequences of ACEs and the “clear impact of stress on the developing brain of a child.” She organized a community meeting in early 2008 and brought Anda in for a two-and-a-half-hour seminar; 165 people showed up.

At the end of Anda’s presentation, a parent named Annett Ridenour walked to the front of the room, and, with tears streaming down her face, took the microphone out of Anda’s hand. “I have 10 ACEs,” she said, “and now I understand my life.”

“This made me believe in the liberating effects of ACEs,” writes Barila in the “Getting Started” chapter of the the Resilience Trumps ACEs Manual. It was also the unofficial start of the Children’s Resilience Initiative.

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The Camden story: A physician and a priest plant seeds of repair

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Simultaneously making changes at the organizational level and building alliances across sectors for larger system change, Father Jeff Putthoff, SJ, and Dr. Jeffrey Brenner realized they had to dig deeper — beyond symptoms to root causes — to understand the struggles they were witnessing in Camden, NJ. What they found were ACEs.

Putthoff, a Jesuit priest known locally as “Father Jeff,” is a fireplug of purpose under his casual uniform of cargo shorts and sweatshirt, earbuds slung around his neck, a blue bicycle his preferred mode of transport. He is voluble and passionate on the subject of his city. Since 2000, Father Jeff has directed Hopeworks N’ Camden, an organization that offers in-school and out-of-school youth GED classes and web-site design instruction—skills intended to parlay directly into jobs or college.

Brenner is equally driven—a physician/scholar/prophet in a slightly rumpled suit, with a calendar so crammed he must set a smartphone alarm to keep his days on track. He is founder and executive director of the Camden Coalition of Healthcare Providers and the recipient of a 2013 MacArthur “genius” grant. In 2011, he was profiled in The New Yorker, which chronicled his innovative plan to shrink the cost of health care by focusing on the highest-risk patients, providing them with team-based interventions to keep them out of hospitals, and by helping them manage chronic illnesses and social/emotional needs.

But it wasn’t until the last three years that each man learned of the CDC Adverse Childhood Experiences Study, whose first study was published in 1998, and began to apply its lessons to his work. That study, of  more than 17,000 Kaiser Permanente members in California, showed that early childhood adversity—including neglect, physical and sexual abuse and parental abandonment—was both widespread and corrosive to long-term physical and mental health. Trauma, the study implied, leaves tracks in the brain and lingers in the body. Stress can literally make people sick.

Putthoff saw the symptoms of that trauma every day. Camden earned the dubious title of “most violent city in America” in 2012, when there were 67 homicides among its 77,000 residents. That year, someone in Camden was shot, on average, every 33 hours. Two out of five Camden residents live below the poverty line. The streets are pocked with nearly 4,000 abandoned homes.

“I’ve been here [in Camden] 16 years,” Putthoff said. “I’ve been chasing the symptoms all those years, trying to change people’s behavior, get them jobs, get people in school. The dawning realization was that we were not dealing with the cause.”

Hopeworks N’ Camden provides training programs in a trauma-informed environment

Putthoff could see how frustration and hopelessness were wearing on the Hopeworks staff—10 full-time and four part-time employees who work to boost students’ reading skills and teach them web site design and GIS (geographic information systems, or

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How the NFL can stop abuse AND keep its players on the field

A young fan wears an Adrian Peterson jersey.  [Photo: Ann Heisenfelt/AP]

A young fan wears an Adrian Peterson jersey. [Photo: Ann Heisenfelt/AP]

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Many people are happy that the Vikings kicked Adrian Peterson off the team and that Ray Rice can no longer play for the Ravens. Their off-field violence has cascaded into harm and loss for everyone involved – spouses, children, team, league and fans — all because of the consequences of their childhood trauma. And the only way the NFL can stop further abuse, harm and loss is…well…to deal with its players’ childhood trauma.

The severe and toxic stresses in Peterson’s past – or what we in the trauma-informed community count on a scale from one to 10 as adverse childhood experiences or ACEs – aren’t minor. As a child, he lost his father to prison, suffered through his parents’ divorce, saw his brother killed by a drunk driver, and was beaten by his stepfather. Repeating the pattern, he whipped his own four-year-old son with a switch so harshly that he raised welts on the child’s body. And if Peterson is convicted and goes to prison, his son can add another ACE to his trauma-filled life.

Peterson and Rice are two of millions of child and spouse abusers who love their families and can learn from their mistakes, if provided with help early enough. The average child abuser or spouse abuser isn’t dirty, disheveled, reeking of alcohol or stoned on meth. Child and spouse abusers are corporate CEOs, ministers, priests, actors, business owners, teachers, truck drivers, physicians, nurses, basketball heroes, journalists, computer programmers, and your next-door neighbors.

They’re dads and moms who have a hard time controlling their emotions when they’re under stress because they themselves were abused. Nobody helped them when they were kids and nobody’s helping them as adults.

Plain and simple, childhood trauma is the nation’s No. 1 public health problem. The CDC’s Adverse Childhood Experiences Study (ACE Study) – the largest public health study you never heard of — shows that childhood trauma is very, very common. (ACE surveys in 22 states echo the results.) And this childhood adversity causes violence, including family violence, as well as the adult onset of chronic disease and mental illness.

By learning about the science of childhood adversity, and following the lead of many other organizations that are becoming trauma-informed, the NFL could have players whose families are happier and healthier, it could have better players (more focused, less stressed), and it might never have to deal with a Ray Rice or Adrian Peterson situation again.

The NFL has 1,696 players. Of those 1,696 players, probably two-thirds – 1,119 young men – have experienced one type of serious childhood trauma. And it’s likely that 22 percent – about 370 players –

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The Philadelphia story: Education and activism converge in “ACEs epicenter”

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The women and men gathered for a training on trauma and resilience were recovery counselors and social workers, charter-school teachers and prison administrators. But to Stephen Paesani, the child and adolescent training specialist who was leading the session, every person in the room was a potential protective factor in a child’s life.

“When a child experiences adversity or trauma, he goes into the fight-or-flight stance,” Paesani explained. “That’s going to impact brain development. “But no matter what happens, all of you can be the agents for resilience.”

Paesani works for Philadelphia’s Behavioral Health Training and Education Network (BHTEN), which provides training to practitioners and community members, part of the city’s effort to infuse mental health and substance abuse services with principles of recovery, resilience and self-determination.

But BHTEN’s trainings are just one piece of the Philadelphia ACEs story. In this city of 1.5 million—a city rife with disparities of class, education and health, with pockets of multi-generational poverty and trickle-down trauma—the last decade has seen a steady effort to bring understanding of adversity, trauma and resilience to thousands of front-line workers, supervisors and administrators across the map of human services.

This work is not the result of a top-down initiative or a single funder’s vision for change. It is, instead, the gradual flowering of multiple seeds, planted by activist leaders in pediatrics, public health, behavioral health, child welfare, justice and education.

Today, Philadelphia is home to the ACE Task Force, a group of 50 practitioners intent on putting the knowledge of brain development, adversity and resilience to work in pediatric and primary care clinics, child abuse prevention networks and early childhood programs. The social network site ACEsConnection.com recently launched a Philadelphia group whose members share questions, successes and challenges.

And thanks to the Institute for Safe Families, with support from the Robert Wood Johnson Foundation, Philadelphia was the site of the first National Summit on ACEs in May 2013, attended by 160 physicians, academics, social workers and human service administrators. There, speakers called the ACEs movement “a revolution” in thinking about health and illness, human suffering and strength.

In Philadelphia, that revolution began even before the groundbreaking Centers for Disease Control Adverse Childhood Experiences Study (ACE Study) demonstrated the lifelong impact of early adversity.

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