Childcare providers use two-generational approach to help preschoolers from being expelled

It’s shocking: Preschoolers are three times more likely to be expelled than children in elementary, middle and high school, according to figures from the U.S. Department of Health & Human Services. Boys are four times more likely than girls to be kicked out, and African American children are twice as likely as Latinx and White children.

One organization with childcare centers and mental health providers in Kentucky and Ohio began a long journey 15 years ago, when they began hearing about young kids getting expelled. By integrating a whole family approach and the science of adverse childhood experiences, the Consortium for Resilient Young Children (CRYC) took a radically different approach to help little kids stay in school.

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Carolyn Brinkmann

“We came together 15 years ago to start addressing the growing need for social emotional supports for young children,” says Carolyn Brinkmann. “Our organizations were getting phone calls from their own programs about younger children being expelled from preschool and childcare, and we tried to figure out how to start responding to that.”

Brinkmann is the director for the Resilient Children and Families Program (RCFP), a coaching and training arm of the CRYC. The CRYC comprises five childcare or educational agencies and three mental health provider agencies in southwest Ohio and northern Kentucky. The RCFP provides coaching and training to around 50 community-based programs that serve around 1,541 children.

Brinkmann and her colleagues began by looking for programs that address stressors and promote resilience in the whole family.

“We’re not working with little ones in a vacuum,” says Whitney Cundiff, the team leader of early childhood services for Northkey Community Care in Covington, Kentucky, part of the consortium. Along with Brinkmann, Cundiff led the research and training for the Consortium and they decided to use something commonly known as a two-generational approach—little kids and their parents or caregivers.

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Whitney Cundiff

In 2008, Brinkmann trained childcare providers in the Strengthening Families Protective Factors approach, a framework developed by the Center for the Study of Social Policy. It includes building resilience in parents, strengthening families’ social connections in their communities, educating parents about child development, and helping parents link up with organizations that can help them when they’re struggling to feed and house their families or provide other basic needs. It does not, however, train people in PACEs science.

Then, in 2016, the RCFP joined a Cincinnati-based collaborative called Joining Forces for Children, a cross-sector collaborative that focuses on building resilience and preventing adversity in children and families. Among its founding members was Cincinnati Children’s Hospital pediatrician, Dr. Robert Shapiro, who was interested in their two-generational focus.

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Youth Detention Facility finds culture of kindness more effective than punishment

A corner of the Multi-Sensory-De-escalation Room. All photos of the MSDR courtesy of Valerie Clark

When a young person enters the de-escalation room in the Sacramento County Youth Detention Facility, they’ll find dimmed lights, bottles of lavender, orange and other essential oils, an audio menu featuring the rush of ocean waves and other calming sounds, along with squeeze balls, TheraPutty, jigsaw puzzles, and an exercise ball to bounce on.

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TheraPutty, squeeze balls and more

Sometimes, with a teen’s permission, “We’ll put a weighted blanket on them, just to give them that hug that feels good, since we can’t give them [real] hugs in our facility,” says Valerie Clark, the probation officer who oversees the room. Giving hugs violates the protocol requiring that staff maintain healthy boundaries with their young charges. But “especially if someone is highly upset and just really crying,” Clark explains, the blanket can be a comforting substitute.

Since it first opened to youth in November 2016, the de-escalation room has been a refuge for kids feeling overwhelming anger, grief, sadness, and anxiety, who are either referred by staff or can request a visit. They stay in it anywhere from 30 minutes up to two hours.

The room is one example of how the Sacramento County Probation Department is shifting its culture to be responsive to adolescent trauma. In 2016, the department sponsored a countywide summit on trauma and the adolescent brain. This February and March, 330 employees from the Youth Detention Facility, and 155 from Juvenile Field, Placement and Court divisions, were trained in the roots of trauma and how to respond to it. And five members of the probation leadership were certified as trainers in trauma-informed practices. The training includes learning about how trauma in childhood can trigger the brain into fight, flight and freeze; can cause depression and lead to disruptive behaviors, and how they can build strength and resilience in the youth they serve.

Prior to having the de-escalation room, says Clark, youth would be sent to their individual rooms when they were disruptive or upset. “This way they have the opportunity to regain control of their emotions and behavior so they can go back to their programs instead of [having to stay] in their room alone with their thoughts,” she explains.

An impetus for the room, known as the Multi-Sensory De-escalation Room, was legislation that was signed into law in California in 2016, says Shaunda Cruz, the deputy chief of field services at the Sacramento County Probation Department and one of the department’s trauma-informed champions.

“The legislation recognizes the impact that trauma, and obviously the impact of coming into a facility, has on young people,” she says. The law, which was sponsored by former California State Senator Mark Leno, limits the use of solitary confinement for minors in detention facilities to four hours, and allows it only when juveniles’ behavior is considered a safety threat and less restrictive options have been exhausted.

Around the same time that the legislation was being developed, members of the county probation department and juvenile court staff were working on a capstone project through a justice reform collaborative out of Georgetown University’s Center for Juvenile Justice Reform. That’s where the idea for an MSDR emerged, says Ruby Jones, assistant chief deputy of the Sacramento County Youth Detention Facility.

Lesson learned integrating ACEs science into health clinics: Staff first, THEN patients

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Dr. Omoniyi Omotoso

About two years ago, a team from LifeLong Medical Clinics jumped at the opportunity to integrate practices based on adverse childhood experiences   when it joined a two-year learning collaborative known as the Resilient Beginnings Collaborative (RBC). RBC began in 2018 and includes seven safety-net organizations in the San Francisco Bay Area. (Here’s a link to a report about the RBC.)

To join the RBC, LifeLong Clinics — which has  14 primary care clinics in Alameda, Contra Costa and Marin Counties — and the other collaborative teams had to agree to introduce all staff members to the science of childhood adversity and trauma-informed practices. LifeLong went full steam ahead with a 2.5-hour introductory training for more than 100 employees who work at its clinics that serve pediatric patients. Trauma Transformed, a program of the East Bay Agency for Children in Oakland, CA, did the training in October and November 2018.

LifeLong Clinics’ decision to move forward on integrating ACEs science and trauma-informed practices into its clinics is important particularly in California where a state policy has made childhood adversity a front and center issue. On Jan. 1, 2020, as an incentive to doctors who serve Californians in the state’s Medicaid program, the state began offering supplemental payments of $29 to doctors for screening the estimated 12 million pediatric and adult patients for adverse childhood experiences (ACEs).

ACEs comes from the groundbreaking Adverse Childhood Experience Study (ACE Study), first published in 1998 and comprising more than 70 research papers published over the following 15 years. The research is based on a survey of more than 17,000 adults and was led by Drs. Robert Anda and Vincent Felitti. The study linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs — including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101Got Your ACE/Resilience Score?)

The ACE surveys — the epidemiology of childhood adversity — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, the epigenetics of toxic stress (how it’s passed on from generation to generation), and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.

After it trained employees in 2018, brainstorming around workflow was provided for staff at the LifeLong Howard Daniel Health Center in Oakland, CA, in February 2019, where LifeLong plans to pilot ACEs screening in newborns to five-year-olds, said Dr. Omoniyi Omotoso, the pediatric lead at LifeLong Clinics, who led the brainstorming about workflow and additional training.

Four months into that training, in June, Omotoso showed staff the ACEs questionnaire and asked them how they thought patients would feel about it.

And that’s when Omotoso realized that they had to put on the brakes. “A lot of the staff were uncomfortable because they themselves had similar instances that they personally were triggered by as they read the [ACE] questions themselves,” said Omotoso, who splits his clinical time between LifeLong Howard Daniel Health Center and LifeLong William Jenkins Health Center. He said that LifeLong will be using the de-identified PEARLS ACE screener for its pediatric population, which asks those surveyed to write on the form the number of ACEs that apply to them. (Here’s a link to ACEs Aware, where you’ll find out more information about PEARLS, the only pediatric ACEs screener for which California providers can be reimbursed.)

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San Mateo (CA) launches county initiative to tackle ACEs and build resilience

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Group ice-breaker exercise

When you’re working with people who’ve had a lot of childhood and adult adversity, it’s hard for you to believe that anyone else can have a bad day, says Laura van Dernoot Lipsky. “Your neighbor or your best friend says: ‘I’ve had a bad day.’ And you think, ‘Oh, I’m sorry you had a bad day; were you sex trafficked today? No, you were not!’”

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Laura van Dernoot Lipsky

Van Dernoot Lipsky, the author of Trauma Stewardship: An Everyday Guide to Caring for Yourself While Caring for Others, was driving home one of several points of how working in a job that serves severely traumatized people can harm people who help them, too.

CA announces robust perinatal depression prevention for Medi-Cal recipients

Melinda Coates experienced a tumultuous pregnancy. “I was really mentally upset literally from day one (of the pregnancy),” she says. (Melinda Coates is a pseudonym. To protect her and her children’s privacy and safety, we are not using her real name.)

Coates had hoped to get counseling last October, when she was seven months pregnant. That’s when she enrolled in the state’s Medi-Cal program, shortly after she and her abusive husband moved to California, “but nobody was able to get me in that quickly,” she says. “If I had gotten the help that I needed with my mental state, I may not have stayed in my abusive marriage as long,” she says.

Six weeks after her son’s birth she had one session with a counselor who prescribed an antidepressant. “I was supposed to go back, and I needed to reschedule, but I never heard from her again,” says Coates, who has been living in a domestic violence shelter since the end of June with her eight-month-old son and three-year-old daughter. She is currently separated and filing for a divorce from her husband.

A new policy in California that went into effect in July now makes it possible for pregnant women like Coates to get the counseling they need, according to a recently-released MediCal bulletin.

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Medical students’ ACE scores mirror general population, study finds

national survey published in 2014 revealed a disturbing finding. Compared to college graduates pursuing other professions, medical students, residents and early career physicians experienced a higher degree of burnout.

Citing that article, a group of researchers at University of California at Davis School of Medicine wondered whether medical students’ childhood adversity and resilience played a role in their burnout, said Dr. Andres Sciolla, an associate professor of psychiatry and behavioral sciences at the University of California at Davis Medical School. Sciolla is the lead author of a recent study in the journal Academic Psychiatry that investigated those questions.

Their query was based on the landmark CDC-Kaiser Permanente Adverse Childhood Experiences Studythat showed a remarkable link between 10 types of childhood trauma — such as witnessing a mother being hit, living with a family member who is addicted to alcohol or who is mentally ill, living with a parent who is emotionally abusive, experiencing divorce — and the adult onset of chronic disease, mental illness, being violent or a victim of violence, among many other consequences. The study found that two-thirds of the more than 17,000 participants had an ACE score of at least one, and 12 percent had an ACE score of four or more. (For more information, see ACEs Science 101.)

The ACE Study and subsequent research shows that people with an ACE score of 4 are twice as likely to be smokers and seven times more likely to be alcoholic than someone with an ACE score of 0. Having an ACE score of 4 increases the risk of emphysema or chronic bronchitis by nearly 400 percent, and attempted suicide by 1200 percent. An ACE score of 6 or higher is associated with a 20-year shorter lifespan than someone with an ACE score of 0. However, subsequent research has shown that social buffers, such as having just one caring adult in a child’s life, can mitigate the impact of ACEs.

For the UC Davis study, 86 third-year medical students completed an ACE survey. Of those, 49% had an ACE score of 0, 40 % had ACE scores between 1-3, and 12 % had ACE scores of 4 or more.

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Shifting the focus from trauma to compassion

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Dr. Arnd Herz

Dr. Arnd Herz, a self-described champion for ACEs science, would like nothing more than to witness a greater appreciation of how widespread adverse childhood experiences are. Herz, a pediatrician and director of Medi-Cal Strategy for the Greater Southern Alameda Area for Kaiser Permanente Northern California, would also like to encourage more people in health care to engage in a trauma-informed care approach, a change in practice that he says not only benefits patients, but also health care providers and their staff.

“It makes so much sense,” say Herz. “This is why I went into medicine. I don’t want to just click off diagnoses, but create relationships and help people by understanding them better, and trauma-informed care is just a way to bring compassion back into the care that we do.”

For the uninitiated, a trauma-informed approach includes an awareness that adverse childhood experiences (ACEs) are common, knowing how to recognize the signs and symptoms of trauma, creating a safe environment where the focus is on “What happened to you?” rather than “What’s wrong with you?”, engaging trauma survivors as equal decision-makers in their care, and offering patients referrals to supportive services as needed, according to a report by the Substance Abuse and Mental Health Services Administration and a primer by the Center for Health Care Strategies.

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The quest to find biomarkers for toxic stress, resilience in children — A Q-and-A with Jack Shonkoff

The JPB Research Network on Toxic Stress, led by Dr. Jack Shonkoff, is working on developing biological and behavioral markers for adverse childhood experiences (ACEs) and resilience that they believe will be able to measure to what extent a child is experiencing toxic stress, and what effect that stress may be having on the child’s brain and development.

The JPB Research Network on Toxic Stress is comprised of scientists, pediatricians and community leaders, and is a project of the Center on the Developing Child at Harvard University.

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Kaiser family medicine clinic launches 4-question ACE survey pilot for adults

In July, medical residents in family medicine at Kaiser Permanente in San Jose, CA, began screening adult patients for adverse childhood experiences (ACEs). But it’s an ACE survey with a twist: it’s shorter, not the  10-question survey of the original CDC-Kaiser Permanente ACE Study, according to Dr. Kathryn Ridout who is leading the pilot along with Dr. Francis Chu and Dr. Alec Uy.

Why a shorter ACE survey?

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“When we were doing our initial discussions with stakeholders in the clinical setting, one of the barriers was the perception of the amount of time it takes to do a screening,” says Ridout. So, she and her colleagues developed a shorter ACE survey of four questions. The questions were adapted from the original ACEs screen of 10 questions as well as expanded ACE surveys that include statements about experiencing bullying or racism, living in a war zone, or in a violent neighborhood. (Since the four-question survey is currently being piloted, it’s not yet available for public release, according to Ridout.)

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Oakland, CA, trying out model used in Baltimore to reduce trauma, increase resilience

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Baltimore BSC faculty and planning team

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When a group of community organizations in Baltimore came together in 2015, they already knew trauma figured large in many lives. There was violence in the community, in schools, and in community members’ homes. Police brutality occurred. Many suffered the loss of loved ones to incarceration or death. There were house fires and homelessness. Much of the dysfunction was systemic and rooted in racism, according to a report on a collaborative effort to restructure city organizations and agencies. The goal was to build community resilience.

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