1. BEYOND ACE OCTOBER 21, 2015

3. CHANGES MADE FOR THIS SECOND ADMINISTRATION OF THE ACE SURVEY: Administration protocols developed by agencies Standardized training for staff administering ACE Use of CHOP data system and external researcher Demographic section broadened to include additional factors, e.g. country of birth, etc. Additional outcomes included, e.g. trafficked for sex, etc. Included administration of well being questions from the domains of connection, stress and coping.

4. PARTICIPATING CRITTENTON AGENCIES ACE Survey – 16 States and 18 agencies: 1.ARIZONA 2.CALIFORNIA (2) 3.FLORIDA 4.ILLINOIS 5.IOWA 6.KANSAS 7.MISSISSIPPI 8.MISSOURI 9.MONTANA 10.NEW YORK 11.NORTH CAROLINA 12.OHIO 13.PENNSYLVANIA 14.SOUTH CAROLINA 15.TENNESSEE (2) 16.WEST VIRGINIA

5. FINDINGS FROM THE SECOND CRITTENTON ACE SURVEY ADMINISTRATION Dr. Roy Wade, Jr. CHILDREN’S HOSPITAL OF PHILADELPHIA AND STONELEIGH FOUNDATION FELLOW

6. OUTCOMES ASSOCIATED WITH ADVERSE CHILDHOOD EXPERIENCES: A LIFE COURSE PERSPECTIVE CHILDHOOD: Fetal Death Developmental Delay Behavioral Problems Cognitive Impairment ADOLESCENCE TO YOUNG ADULTHOOD: Mental Health Academic Achievement Juvenile Justice ADULTHOOD: Mental Health Physical Health Disability Early Mortality

7. CDC/KAISER ADVERSE CHILDHOOD EXPERIENCE STUDY CHILDHOOD EXPOSURE SUBCATEGORY Abuse Psychological Physical Sexual Household dysfunction Substance abuse Mental illness Intimate partner violence Criminal behavior Divorce Neglect Emotional Physical Published by CDC/Kaiser in 1998 Surveyed 17,000 policy holders Understand relationship between childhood adversity & adult health outcomes Adapted from Felitti et al., 1998

8. HEALTH OUTCOMES ASSOCIATED WITH ADVERSE CHILDHOOD EXPERIENCES HEALTH RISK BEHAVIORS MENTAL HEALTH CONDITIONS PHYSICAL HEALTH CONDITIONS Smoking Alcohol Abuse Drug Abuse/Illicit Drug Use High Risk Sexual Behavior Depression Anxiety PTSD Hallucinations Suicide Cardiovascular Disease Diabetes Emphysema Cancer Obesity Liver Disease Headaches Autoimmune Disease Sexually Transmitted Infections Self-Reported Health Disability Fetal Death Mortality Health outcomes highlighted in pink are among the top ten leading causes of death in the US

9. PHILADELPHIA ACE STUDY QUESTIONS CONVENTIONAL ACESEXPANDED ACES Physical Abuse Emotional Abuse Sexual Abuse Emotional Neglect Physical Neglect Domestic Violence Household Substance Abuse Incarcerated Care Provider Mental Illness in the Home Witnessing Violence Living in Unsafe Neighborhoods Experiencing Racism Living in Foster Care Experiencing Bullying

10. PHILADELPHIA STUDY - DISTRIBUTION OF TOTAL ACE SCORES Prevalence (%) ACE Score

11. TNCF SURVEY RESPONDENTS WERE PRIMARILY FEMALE, WHITE, AND LESS THAN 18 YEARS OF AGE DEMOGRAPHICRESPONSE FEMALE (N = 745) MALE (N = 270) TOTAL (N = 1021) Age in years (%) 10 to 18728973 19 to 3419815 35 to 65938 Gender (%) Female-- 74 Male-- 26 Race/Ethnicity (%) Hispanic/Latino163119 White545055 Black201117 Multiracial565 Other524 Education (%) Less than high school759280 High school14511 Some college or more1239

12. TNCF SURVEY RESPONDENTS PRIMARILY RECEIVED MENTAL HEALTH SERVICES FEMALE (N = 745) MALE (N = 270) TOTAL (N = 1021) Early childhood (%)411 Family support (%)413 Mental & behavioral health (%)376245 Supportive housing (%)1058 Residential treatment (%)201530 Other (%)545 Don’t know/refused (%)19118

13. TNCF SURVEY RESPONDENTS LIVE IN A VARIETY OF SETTINGS FEMALE (N = 745) MALE (N = 270) TOTAL (N = 1021) Foster care/kinship foster care (%)7179 Group home (%)12911 Living on my own (%)13711 Living with friends (%)101 Living with my biological or extended family (%) 275135 Residential treatment center (%)291124 Shelter (emergency, domestic violence, homeless) (%) 937 Other (%)202

14. TNCF CLIENTS HAVE HIGHER ACE SCORES THAN RESPONDENTS FROM PREVIOUS ACE STUDIES (TNCF Total N=1,008, TNCF Female N=732, Philadelphia N=1,784, Kaiser-CDC N=17,337)

15. TNCF CLIENTS HAVE HIGHER ACE PREVALENCE THAN INDIVIDUALS FROM PREVIOUS ACE STUDIES

16. TNCF FEMALE RESPONDENTS HAVE HIGHER ACE SCORES THAN TNCF MALE RESPONDENTS (Female N=732, Male N=245)

17. TNCF FEMALES HAVE HIGHER PREVALENCE OF ACES THAN MALES

18. HIGH ACES FOR TNCF FEMALES CUT ACROSS ALL RACIAL/ETHNIC BACKGROUNDS

19. ALL ACES ARE COMMON AMONG TNCF FEMALES WITH SIGNIFICANT CHILDHOOD ADVERSITY (N=732)

20. FEMALES WITH HIGH ACE SCORES EXPERIENCE MORE PLACEMENT INSTABILITY

21. A SIGNIFICANT NUMBER OF TNCF FEMALES RECEIVING SERVICES FOR AT LEAST 1 YEAR HAVE HIGH ACE SCORES

22. A SIGNIFICANT PERCENTAGE OF TNCF FEMALES RECEIVING RESIDENTIAL TREATMENT SERVICES HAVE HIGH ACE SCORES

23. A SIGNIFICANT PERCENTAGE OF TNCF FEMALES WITH TEENAGE PREGNANCIES OR RAISING CHILDREN HAVE HIGH ACE SCORES

24. ACES ASSOCIATED WITH HISTORY OF TRAFFICKING AMONG TNCF FEMALES ( N=56)

25. CHILD DEMOGRAPHICS (N=109) DEMOGRAPHICSRESPONSEPERCENT Age in years (%) 0 to 653 7 to 108 11 to 1831 Gender (%) Female47 Male53 Race/Ethnicity (%) Hispanic26 White33 Black27 Multiracial8 Other7

26. INDIVIDUAL ACES ARE COMMON AMONGST CHILDREN OF TNCF FEMALES (N=109)

27. CHILDREN OF TNCF FEMALES HAVE HIGH ACE SCORES (N=109)

28. AVERAGE CHILD ACE SCORE BY AGE (N=109)

29. PSYCHOLOGICAL STRESS INCREASES WITH ACE SCORE FOR TNCF FEMALES (N=664)

30. CONNECTION TO OTHERS DECREASES WITH ACE SCORE FOR TNCF FEMALES (N=664)

31. COPING SKILLS DECREASE WITH ACE SCORE FOR TNCF FEMALES (N=664)

32. POLICY AND PRACTICE IMPLICATIONS The following policy and practice implications are made based on inferences drawn from the results from respondents in this administration of ACE. Further research must be completed before definitive findings and recommendations can be made.

33. POLICY AND PRACTICE IMPLICATIONS FINDING: There’s a group of girls for whom ACEs are normative  Policy Implication: We must focus on reducing overall exposure to ACE’s and other forms of adversity. FINDING: Girls’ ACE scores are higher than boys and there are differences in prevalence on individual ACEs.  Policy Implication: A gender lens should be used in all systems to better understand appropriate service responses for girls.

34. POLICY AND PRACTICE IMPLICATIONS (continued) FINDING: Girls with very high ACE scores (8+) have a high number of placements and more likely to be trafficked for sex  Policy Implication: The traditional approach of looking at scores of 4+ misses the unique needs of girls with very high ACE scores. More attention needs to occur for young women with significant childhood adversity FINDING: ACES are prevalent for individuals across racial and ethnic groups  Policy Implication: It’s important to eradicate the negative impact of bias in systems against girls of color is eradicated, while also making sure that low income white girls in rural areas are not further marginalized.

35. POLICY AND PRACTICE IMPLICATIONS (continued) FINDING: Children of parents with high ACEs experience adversity at young ages:  Policy Implication: A two or multi-generational approach offers the best opportunity for parents with high scores to break the vicious cycle of childhood adversity, trauma, poor outcomes and poverty. FINDING: Initial results suggest a connection between ACE scores and well being:  Policy Implication: Further work on how to increase connections for young people, research on a wider range of well being domains, and follow up research to explore which interventions work to promote well being

36. NEXT STEPS: BEYOND ACE Further analysis of the data. Publication of a policy brief on findings and implications of the TNCF ACE data in late November. Population specific issue briefs will be generated over the next six months.

37. NEXT STEPS: EVIDENCE BUILDING PROCESS Pending funding TNCF will: Work with Dr. Wade to develop and administer a girl/youth informed survey based on the ACE. Develop central data base for demographic, ACE and well being data across agencies/states. Administer well being questions in additional domains beyond connection, stress and coping.