ACEs and School-based Health

1. ACEs and School-based Health January 8, 2014 Sarah Wilhelm, MPH Public Health Seattle & King County

2. What do you know about the relationship between “adverse childhood experiences” (ACEs) and health?

3. ADVERSE CHILDHOOD EXPERIENCEs The Most Powerful Determinate of the Public’s Health • Abuse and Neglect • Child physical abuse • Child sexual abuse • Child emotional abuse • Neglect • Indicators of Family Dysfunction • Mentally ill, depressed or suicidal person in the home • Drug addicted or alcoholic family member • Witnessing domestic violence against the mother • Parental discord – indicated by divorce, separation, abandonment • Incarceration of any family member ACE Score: the number of categories of adverse childhood experience to which a person was exposed.

4. ACEs Influence Via Biologic Impact on Neurodevelopment • INDIVIDUAL • Edgy • Hot temper • Impulsive • Hyper vigilant • “Brawn over brains” OUTCOME Individual & species survive the worst conditions. BRAIN Hormones, chemicals & cellular systems prepare for a tough life in an evil world TRAUMATIC STRESS NEUTRAL START • INDIVIDUAL • Laid back • Relationship-oriented • Thinks things through • “Process over power” OUTCOME Individual & species live peacefully in good times; vulnerable in poor conditions BRAIN Hormones, chemicals & cellular systems prepare for life in a benevolent world

5. ACEs have many impacts throughout the lifespan PSYCHIATRIC DISORDERS Chronic Disease CRITICAL & SENSITIVE DEVELOPMENTAL PERIODS Early childhood, ages 7-9, Pre-puberty, Aging into adulthood IMPAIRED COGNITION Work/SchoolAttendance, Behavior, Performance ADVERSE CHILDHOOD EXPERIENCE MORE CATEGORIES – GREATER IMPACT Physical Abuse, Sexual Abuse Emotional Abuse, Neglect Witnessing Domestic Violence Depression/Mental Illness in Home Incarcerated Family Member Substance Abuse in Home Loss of a Parent BRAIN DEVELOPMENT Electrical, Chemical, Cellular Mass ADAPTATION Hard-Wired Into Biology OBESITY ALCOHOL, TOBACCO, DRUGS RISKY SEX GENETICS Including gender – Remember that experience triggers gene expression (Epigenetics) CRIME intergenerational transmission, disparity poverty

6. In the lives of Washingtonians: ACEs co-occur / cluster 26% of adults report 3 or more ACEs 5% of adults have 6 or more ACEs Among adults exposed to physical abuse, 84% reported at least 2 more ACEs Among adults exposed to sexual abuse, 72% reported at least 2 more ACEs

7. A CLASSIC CAUSAL RELATIONSHIP MORE ACEs = MORE HEALTH PROBLEMS Dose-response is adirect measure of cause & effect. The “response”—in this case the occurrence of the health condition—is caused directly by the size of the “dose”—in this case, the number of ACE categories. Response gets bigger Dose gets bigger

8. Behavioral health Chronic disease

9. Mental health disability

10. In the average Washington classroom: • 6 students have no ACE • 5 students have 1 ACEs • 6 students have 2 ACEs • 3 students have 3 ACEs • 7 students have 4-5 ACEs • 3 students have 6+ ACEs Knowing the prevalence of ACEs and how they affect brain development, it’s clear to see why so many students struggle to focus in an academic environment. ACEs in WA High Schools Graphic by Northwest Children’s Fund, 2012

11. Adult Adversity Incarceration Victim of Intimate Partner Violence Drug/Alcohol Mental Illness Divorce In Washington…. Parenting Adults with ≥5 ACE 14 TIMES more likely to have two or more conditions that make ACEs for kids Court-Involved Youth Higher ACE Scores Among those with ≥4: 51% special ed. (vs. 33% 0-1) 74% below 2.0 GPA (58%) 85% suspended by 2nd(71%) 33% re-offend in 2 years (13%) High School Youth 42% ≥ 3 ACEs Work injury- illness Homelessness Disability Poverty Health limits activity Unemployment Elementary Children 12% ≥ 3 ACEs 1. Health, attendance, behavior 2. Academic failure

12. Community Variation In Some King County Communities… 41% of Parenting Adults have an ACE Score of ≥ 3 In Other Communities… 6% of Parenting Adults have an ACE Score of ≥ 3 (Washington State Prevalence among all adults is just over 26%) Preliminary Analysis, BRFSS Data 2009-2011. Slide courtesy of Laura Porter, DSHS

13. ACEs Are… Not The Whole Story Some Communities with High ACE Prevalence Also Have High Levels of Social/Emotional Support Preliminary Analysis, BRFSS Data 2009-2011. Slide courtesy of Laura Porter, DSHS

14. Social/Emotional Support as a resilience factor Rarely/Never Receive Support Sometimes Receive Support Always/Usually Have Support

15. Building Adult Capabilities to Improve Child Outcomes:A Theory of Change http://developingchild.harvard.edu/resources/multimedia/videos/theory_of_change/

16. Resilience Occurs at All Levels The natural human capacity to navigate life well. (HeavyRunner & Marshall, 2003) Community

17. Trauma-Informed Schools: CLEAR Project Goal: to improve school practices by increasing social emotional success and mitigation of trauma effects to improve school outcomes. • CLEAR: Collaborative Learning for Educational Achievement and Resiliency • Professional development, consultation and direct service model to integrate evidence-based Social Emotional Learning practices. 3 year project funded by Bill and Melinda Gates Foundation at Olympic Hills and Beacon Hill

18. Partners • Washington State University - Area Health Education Center (WSU-AHEC) • Lead technical partner • Seattle Public Schools • Olympic Hills Elementary • Beacon Hill International School (BHIS) • City of Seattle Office for Education • Odessa Brown Children’s Clinic/Seattle Children’s • Sponsor of SBHC at BHIS

19. Implementation • Annual full-day professional development for all building staff • Monthly full-day school visits by WSU AHEC Associate Directors • Lead development and implementation of Response to Intervention (RTI)-guided school response strategy • Classroom observation, individual consultation and coaching, integration of trauma-informed practices into building policies • Ongoing support to building and partners in-person and via distance

20. Partners: Role of SBHC/Odessa Brown • OBCC started school-based health services at Beacon Hill International School (BHIS) in 2012-2013 school year • OBCC participating in program planning, implementation and evaluation of CLEAR Project at BHIS • No school-based health center at Olympic Hills Elementary

21. Outcomes • Implementation of evidence-based trauma-informed social and emotional learning programs. • Adoption of trauma-informed teaching practices in an adapted attachment, self-regulation and competency (ARC) Model. • Effective implementation of an identification, referral, and engagement strategy based on response-to-intervention (RTI) principles in schools to address children not making adequate progress because of trauma’s effects. • How will collaboration with OBCC/SBHC affect program implementation and outcomes at BHIS?

22. CLEAR Project Year 1: Relationship-building and start up • New principals and vice principals at both schools; new staff among partner organizations • WSU AHEC Director Dr. Chris Blodgett to present ACEs/CLEAR Project work to OBCC providers; SPS Positive Climate and Discipline Advisory Committee in early 2014

23. CLEAR Project Year 1: Building Highlights • Olympic Hills ended practice of taking away recess as a discipline policy • CLEAR Project working with staff to identify more appropriate strategies for address behavior issues • BHIS reviewing lunchroom practices, aiming to ease chaotic transition periods that are difficult for students and staff

24. Discussion • How do you incorporate trauma-informed practices into your work? • With the individual students you work with? • School-wide? • How might you help to create a trauma-informed culture at your schools?

25. Thank you!