Sue Mackey Andrews will talk to anyone about adverse childhood experiences, or ACEs: Pediatricians. Early childcare workers. Parent advocacy groups. And those on the front lines who work with kids, like the longtime school bus driver from rural Maine, a gruff and taciturn man who insisted, during a half-day school district inservice, that trauma and resilience had nothing to do with his work.
The driver also told Andrews that he would not start the bus each day until he had made eye contact with every single child and greeted him or her by name. And that, Andrews responded, was exactly the relevance of his work to build resilience.
The tagline of the Maine Resilience Building Network (MRBN), which Andrews co-facilitates, is “Join the Conversation.” The
group, formed in the spring of 2012, brings together practitioners in medical care, education and behavioral health, along with those working in business, law enforcement, the military, juvenile justice and faith communities.
Since its early meetings, comprising a half-dozen people, all of them doing work based on research into childhood adversity, MRBN has grown to include 77 members, with reach into all of Maine’s 16 counties.
From the beginning, said Andrews and MRBN co-facilitator Leslie Forstadt, associate professor with the University of Maine Cooperative Extension, the group agreed that the message should focus on wellness and healing rather than illness and trauma.
The word “resilience” had to be part of the name because, said Andrews, “we talk about how it’s never too late to realize your ACEs and, through support and personal discovery, overcome them.” The term “building” captured the sense of a growing effort, and “network” aptly described how individual sites would function autonomously while sharing their innovations, challenges and questions.
The term “ACEs” has its origins in the CDC-Kaiser Adverse Childhood Experiences Study. The study revealed a direct link between 10 types of childhood adversity and the adult onset of chronic disease (cancer, heart disease, diabetes, autoimmune diseases, etc.), mental illness, violence and being a victim of violence. It showed that childhood trauma was very common — two-thirds of adults have
experienced at least one type. It showed that if people had experienced one, they usually experienced more. And the study showed the more types of trauma experienced, the higher the risk of chronic disease and mental illness. For example, an ACE score of 4 increased the risk of suicide by 1200 percent and alcoholism by 700 percent.
MRBN began small, growing mostly by word-of-mouth and remaining committed to a model of “collective impact”—the understanding that no single agency or program can solve a complex social problem, but each can work to advance a shared mission. The collective impact model calls for a “backbone organization” that does the work of convening and communicating among members; together, Andrews and Forstadt are the spine of MRBN.
This is MRBN’s mission: “To promote resilience in all people by increasing and improving our understanding of traumas and stressors such as ACEs and why they matter.” And while the network has grown to include geriatricians and experts in adolescent medicine, its focus is primarily on children, pre-natal to age five, and their families—which, today, includes teen parents and grandparents who are raising children. “That’s where we felt we could have the biggest impact,” Andrews said.
Even before MRBN, Maine was primed to think about trauma and resilience. The state is New England’s poorest, with one in four children being raised in poverty (the national average is 1 in 5). In the rural “rim” counties, the child poverty rate is a sobering one in three. Unemployment is higher than in nearby Vermont and New Hampshire; many children lack school readiness, and the incidence of domestic violence is on the rise.
Prior to the 1998 publication of the ACE Study, co-founded by Drs. Robert Anda and Vincent Felitti, Maine had received several federal grants for trauma-related work with children and adults, including one called the “We Remember” project, given to the Passamaquoddy Tribe to create a community-based, culturally competent system of care for children with severe emotional and behavioral disorders. By the time Felitti first visited the state, in 2005, his work brought confirming data to what many practitioners had been witnessing for years.
Andrews remembers that “aha” moment. “When I first heard Dr. Felitti talk, I remember thinking not only how it applied to my professional work but also to my family of origin.” That happens often, she said, in educational sessions about ACEs, which encourage participants to reflect on their own experience as a way of understanding the research about early adversity and its impact on health and behavior.
But a single “aha” is not enough to change minds—let alone practice and policy—across a state of 1.3 million people. Since 2005, Felitti and other nationally known experts on trauma and resilience, including Dr. Jack Shonkoff of the Center on the Developing Child at Harvard University, have visited Maine numerous times. Felitti has spoken to the Child Abuse Action Network and the Maine Academy of Pediatrics; he has talked with juvenile justice officials, social workers and psychiatrists. He was interviewed on Maine Things Considered, a public radio program.
These visits brought the research on ACEs to a variety of Maine audiences. Adversity and resilience became more familiar concepts to practitioners, who learned through multiple exposures to the information and opportunities to ask questions.
Initially, Maine’s work on adversity and resilience gained support at the highest levels of state government. By 2005, the governor’s Children’s Cabinet had declared addressing ACEs in policy and practice to be one of its top 3 priorities. The Maine Children’s Growth Council, formed by statute in 2007, reflects an understanding of ACEs in its mission to develop and maintain “sustainable social and financial investment in healthy development of [Maine’s] young children and their families.”
Even so, knowledge about ACEs was slow to spread. In 2011, the Health Accountability Team of the Maine Children’s Growth Council conducted a statewide survey to learn whether practitioners knew about the ACE research and if they were applying it in their work. They surveyed health care providers, early care and education providers, legislators, mental health professionals, law enforcement officials and members of the business community.
The Maine ACEs Study, published in December 2011, found that fewer than 1/2 the respondents knew about Anda’s and Felitti’s original ACE Study, though nearly all thought it was “important” or “very important” to understand how early trauma shaped adult outcomes.
But after some time and discussion, the group decided instead to fund collective projects such as ACEs Summits—educational events held around the state—and a family resilience support curriculum, currently in the pilot stage.
The ACE Summits have proven to be an effective vehicle for spreading information and catalyzing action. Because a presentation that focuses only on adversity can be “a little heavy,” Forstadt said, “and leave folks without tools for what to do,” the ACE Summits combine a session on “ACEs 101” with a longer focus on resilience and intervention.
“For every 35 people you present to, there will be at least one or two who are really jazzed,” Forstadt said. The Summits aim to give those people strategies, skills and concrete ways to get involved. MRBN has conducted seven ACE Summits, with 14 scheduled for 2014; Andrews has fielded requests from school districts, tribal groups and county governments.
Meanwhile, MRBN has helped to support local innovation around ACEs, such as the “resilience bookmark,” a glossy card with a succinct definition of resilience, developed by the G.E.A.R. Parent Network, a parent support and educational network that is also a member of MRBN. Two school systems want to pilot ACE screenings as part of their in-home visits to all pre-kindergarten children, and a dozen pediatric or family practices statewide are interested in incorporating ACE screenings.
And the conversations continue. Andrews and Forstadt are working to build a speakers’ bureau to provide consistent trainings that can be offered statewide; the MRBN web site directs users to news and resources about ACEs. Forstadt wrote an op-ed about ACEs for the Bangor Daily News, Maine’s second largest newspaper.
“ACEs don’t belong to any one group or discipline in our state,” Andrews said. “When we do a session or a meeting at the local level, it’s done on an inter-agency, inter-disciplinary basis.”
While that diversity is a strength, it also requires faith in the collective impact framework and respect for the different ways that various organizations approach the work. “Collective impact honors diversity of thought, what people bring to the table, and it acknowledges that this kind of work takes time,” Andrews said.
As MRBN grows, one challenge is to ensure that new members understand and are faithful to the network’s mission, which includes responsible and sensitive use of any ACE screenings. Recently, an organization interested in MRBN membership said it planned to use the ACE survey for data collection only, not to foster conversations or interventions with clients.
That violated MRBN’s commitment to avoid inflicting further trauma; Andrews talked with the group’s membership and decided that organization was not suitable for MRBN. “Now I do an orientation to MRBN at every other meeting and go over what we expect,” she said.