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

Thank You!

Karen Hudson- hudsonk@email.chop.edu

Stephanie Krauthamer Ewing- ek469@drexel.edu

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

rolasin@cfhnyc.org

Karen Hudson PhD, MSW ,LSW,

Children’s Hospital of Philadelphia

HUDSONK@email.chop.edu

Stephanie Krauthamer Ewing ,PhD., MPH

Drexel University

ek469@Drexel.edu

Sarah Kimball, MPH,

Bronxworks

skimball@bronxworks.org

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/