1. ACEs and Trauma Therapy for Parents of Infants and Toddlers in Foster Care Best for Babies Lunch and Learn June 22, 2015 Marcia Stanton, MSW

2. The Birth Lottery

3. Scientific Advances Are driving a paradigm shift in understanding how child development impacts human health and disease across the lifespan

4. Emerging Awareness Early experiences and genetic predispositions influence development of: adaptive behaviors learning capacities lifelong physical and mental health future economic productivity

5. The Adverse Childhood Experiences (ACE) Study “Probably the most important public health study you never heard of.” ACEs sometimes referred to as: – toxic stress – childhood trauma – childhood adversity

6. ACEs Often Last a Lifetime... But They Don’t Have To Healing can occur Cycle can be broken Safe, stable, nurturing relationships heal parent and child

7. Two Categories of ACEs 1)Abuse or Neglect - Recurrent physical abuse - Recurrent emotional abuse - Sexual abuse - Emotional or physical neglect 2) Household Dysfunction - Alcohol or drug abuser - Incarcerated household member - Someone chronically depressed, suicidal, institutionalized or mentally ill - Mother being treated violently - One or no parents

8. What Do ACEs Look Like?

9. Why is This Study So Important? ACEs are: Surprisingly common Strong predictors: -social functioning -well-being -health risks -disease -death

10. Public Health Enemy # 1 “Children’s exposure to ACEs is the greatest unaddressed public health threat of our time.” Dr. Robert Block, former president, American Academy of Pediatrics

11. Science is Clear Toxic stress caused by ACEs can profoundly alter the otherwise healthy development of a child

12. Physical, Mental & Behavioral Outcomes of ACEs Alcoholism & alcohol abuse Chronic obstructive pulmonary disease & ischemic heart disease Depression Fetal death High risk sexual activity Illicit drug use Intimate partner violence Liver disease Obesity Sexually transmitted disease Smoking Suicide attempts Unintended pregnancy *** The higher the ACE Score, the greater the incidence of co-occurring conditions from this list.

13. ACE Scores 1/3 of Adults have ACE Score of 0 Majority of adults with ACE score of 0, have few, if any, risk factors for diseases that are common causes of death in US

14. 4 or more may result in multiple risk factors for chronic diseases or disease themselves 6 or more may result in a 20 year decrease in life expectancy

15. If Any One ACE is Present 87% chance at least one other ACE is present, and 50% chance of 3 others

16. What is a High ACE Score? Tipping Points Seem to Occur at 4 and 7

17. ACEs are Interrelated and Predictive Without interruption, ACEs escalate across generations (nature and nurture)

18. ACEs Have Cumulative Stressor Effect It’s the number of different categories, not the intensity or frequency, that determine health outcomes

19. It’s Not All About High Risk Coping Measures Even if individuals with high ACE Scores do not adopt high risk behaviors, they are still much more likely to have negative health consequences

20. National Survey of Children’s Health Telephone survey Tracks parent report of their children’s ACEs (does not include child maltreatment or neglect) 2011/12 data http://www.childhealthdata.org

21. Arizona Children, 0 – 17 ( 2011/2012 National Survey of Children’s Health) No ACEs - 42.5 % One ACE - 26.4 % Two + ACEs - 31.1 % (Natl. average: 22.6 %)

22. Arizona Children, 0 - 5 ( 2011/2012 National Survey of Children’s Health) No ACEs – 54.7% One ACE – 28.6% Two or More ACEs - 16.7% (National Average 12.5%) Ethnic minorities higher share Est. 69,213 AZ children 5+ ACEs

23. Children exposed to 5+ significant adversities in first 3 years face a 76% likelihood of having one or more delays in development.

24. Kids in AZ with 5+ ACES Would Fill University of Phoenix Stadium

25. Or, Equal Population of Flagstaff

26. With 0 ACEs 1 in 16 smokes 1 in 69 are alcoholic 1 in 480 use IV drugs 1 in 14 has heart disease 1 in 96 attempts suicide With 0 ACEs 1 in 16 smokes 1 in 69 are alcoholic 1 in 480 use IV drugs 1 in 14 has heart disease 1 in 96 attempts suicide With 3 ACEs 1 in 9 smokes 1 in 9 are alcoholic 1 in 43 use IV drugs 1 in 7 has heart disease 1 in 10 attempts suicide With 3 ACEs 1 in 9 smokes 1 in 9 are alcoholic 1 in 43 use IV drugs 1 in 7 has heart disease 1 in 10 attempts suicide With 7+ ACEs 1 in 6 smokes 1 in 6 are alcoholic 1 in 30 use IV drugs 1 in 6 has heart disease 1 in 5 attempts suicide With 7+ ACEs 1 in 6 smokes 1 in 6 are alcoholic 1 in 30 use IV drugs 1 in 6 has heart disease 1 in 5 attempts suicide 33% Report No ACEs 33% Report No ACEs 51% Report 1-3 ACEs 51% Report 1-3 ACEs 16% Report 4-10 ACEs 16% Report 4-10 ACEs Out of 100 people…

27. Estimated # Children with 5+ ACEs

28. Toxic Stress “Extreme, frequent or extended activation of the body’s stress response, without the buffering presence of a supportive adult.” Sara B. Johnson, et al., The science of early life toxic stress for pediatric practice and advocacy, 131 PEDIATRICS 319 (2013), available at http://pediatrics.aappublications.org/content/131/2/319.fullhttp://pediatrics.aappublications.org/content/131/2/319.full

29. Children and Stress Biologically predisposed to more physiologic stress Brain structures that modulate this stress mature later Young children need safe, stable, and nurturing relationships to assist in regulating their stress

30. “The 4 th Vital Sign” 1)Respiration 2) Heart Rate 3) Blood pressure 4) Relationships To heal from toxic stress, children need recognition and understanding from their caregivers

31. Relational Health is Key “Healthy attachment, extended family, supportive communities, are more important predictor than developmental adversity” (ACEs). Bruce Perry, MD

32. Getting Things Right the First Time Creating the right conditions in early childhood is more effective and far less costly than addressing a multitude of problems later on

33. Consequences of Not Getting It Right

34. Impact of Stress on Children Flight, fight or fright (freeze) response Short attention span Struggle learning; fall behind in school Respond to world as constant danger Distrustful of adults Unable to develop healthy peer relationships Feel failure, despair

35. “Dropouts Cost AZ $7.6 Billion” The Arizona Republic, June 26, 2014 AZ Dept. of Education: 22 percent of Arizona 9th graders will not finish high school By 2018, more than 60 percent of jobs in AZ will require some post- secondary education

36. ACEs are a Pipeline to Prison Childhood and Adult Trauma Experiences of Incarcerated Persons and Their Relationship to Adult Behavioral Health Problems and Treatment) Intl. Journal of Environ Res Public Health. 2012 May; 9(5): 1908–1926. Published online 2012 May 18. Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense.Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense

37. ACEs and Addiction Findings suggest: A major factor, if not the main factor, underlying addiction, is ACEs that have not healed and are concealed from awareness by shame, secrecy, and social taboo. “It’s hard to get enough of something that almost works.” Vincent Felitti, MD

38. ACEs in Foster Care More than half of kids reported for child maltreatment experienced 4 or more ACEs first contact with child welfare More than 90% have experienced multiple ACEs (Nat’l Survey Child and Adolescent Well-Being (NSCAW), No. 20: Adverse Child Experiences in NSCAW, 2013)

39. Children who experienced 4+ ACEs are three times as likely to take ADHD medication when compared with children with less than 4 ACEs (Ruiz "How Childhood Trauma Could Be Mistaken for ADHD", The Atlantic, 7 July 2014)"How Childhood Trauma Could Be Mistaken for ADHD"

40. Economic Impact Total Estimated Lifetime Impact of All Social Costs and Lost Earnings Associated with Non-Fatal and Fatal Child Maltreatment Incidence in 2014 on Business Activity US - $ 5.8 Trillion AZ - $141.8 Billion (Suffer the Little Children Report, November 2014, The Perryman Group)

41. Getting on Board Public and policymakers are catching on to science of toxic stress Prestigious organizations collecting and reporting on data

43. ACEs Legislation Federal - Children’s Recovery from Trauma Act, June, 2015 Washington, Wisconsin, Vermont, California Could Arizona be next?

44. Huge Social, Public Health Problem – Current investments in response; prevention must be part of solution – Broad societal and community level change needed – Individual level change not sufficient

46. What It Takes “If we want breakthrough outcomes for kids, then we have to transform the lives of the adults that care for them.” (Jack Shonkoff, MD, Center for the Developing Child, Harvard)

47. Two Generation Approach Connect the dots between past, present and future “Parents’ outcomes and children's outcomes are so tightly linked, developing two- generational policies is imperative, not optional.”

48. Public Health Response We Need a Coordinated Multi-level Prevention Effort that Reaches Every Community

49. Positive Factors That Counterbalance Adversity

50. At Least 1 Stable, Caring and Supportive Relationship

51. Building Sense of Mastery over Their Life Circumstances

52. Strong Executive Function and Self- Regulation Skills

53. Affirming Faith or Cultural Traditions

54. Growing Body of Research Eliminating toxic stress among children would have a profound impact on the health and well-being of individuals and entire populations.

55. Early Relationships Build Their Brains and Our Future Child development is foundation for community and economic development

56. In Summary “It is easier to build strong children than to repair broken men” ~ Frederick Douglass (1817-1895) Marcia Stanton, MSW, mstanto@phoenixchildrens.comstanto@phoenixchildrens.com

57. So What Does This Mean? For Our Kids? Our Families? Our Schools? Our Communities? Our Economy? Our Future?

58. This is Where You Come In! What Can We Start Doing Today to Reduce ACEs and Build Stronger Communities?

59. Information & Resources ACE Study findings and information - www.acestudy.org or www.cdc.govwww.acestudy.orgwww.cdc.gov ACEs Too High – www.acestoohigh.comwww.acestoohigh.com National Scientific Council on the Developing Child at Harvard University - www.developingchild.netwww.developingchild.net SAHMSA – Early Childhood Trauma Resources http://www.samhsa.gov/children/earlychildhoodmat.asp http://www.samhsa.gov/children/earlychildhoodmat.asp

60. More Information & Resources National Center for Trauma-Informed Care – www.mentalhealth.samhsa.gov/nctic www.mentalhealth.samhsa.gov/nctic National Child Traumatic Stress Network – www.nctsnet.org www.nctsnet.org Center for Study of Social Policy - strengthening families and protective factors – www.cssp.orgwww.cssp.org Center for Injury Prevention and Control – www.cdc.gov/violenceprevention www.cdc.gov/violenceprevention American Psychological Assn – Resilience Guide - http://www.apa.org/helpcenter/road-resilience.aspx http://www.apa.org/helpcenter/road-resilience.aspx

61. More Resources 3 ½ hour ACE Online Course - $29 - http://www.fpc.wa.gov/acecourse.html http://www.fpc.wa.gov/acecourse.html Ready Nation– http://www.readynation.org/http://www.readynation.org/ Resiliency Trumps ACEs – http://www.resiliencetrumpsaces.org http://www.resiliencetrumpsaces.org Healing Neen - http://healingneen.com/http://healingneen.com/ NCAN Resource Booklet - https://www.childwelfare.gov/preventing/preventionm onth/resource-guide/ https://www.childwelfare.gov/preventing/preventionm onth/resource-guide/ ACE Response Network – http://www.aceresponse.org/ttp://www.aceresponse.org/

62. Works Cited ACE Study: The CDC Adverse Childhood Experiences (ACE) Study homepage presents a wealth of information on the ACE Study including a complete bibliography of ACE Study publications by topic area (http://www.cdc.gov/ace/index.html).http://www.cdc.gov/ace/index.html Early Brain Development: The Center for the Developing Child at Harvard University has a wealth of the latest research and resources on the science of early childhood (http://developingchild.harvard.edu/ ).http://developingchild.harvard.edu/ The Zero to Three Institute has many resources on the impact of trauma and building resiliency in young children (http://www.zerotothree.org/maltreatment/trauma/trauma.html ).http://www.zerotothree.org/maltreatment/trauma/trauma.html First Things First has great info on the science of early brain development (http://www.azftf.gov/why/evidence/pages/brainscience.aspx ).http://www.azftf.gov/why/evidence/pages/brainscience.aspx National Child Traumatic Stress Network: www.nctsnet.org www.nctsnet.org