William H. Dietz MD, PhD Chair, Redstone Global Center for Prevention and Wellness

1. A Pair of ACES William H. Dietz MD, PhD Chair, Redstone Global Center for Prevention and Wellness

2. Outline ACEs criteria Insights from the epidemiology of ACEs Consequences The pair of ACEs

3. Adverse Childhood Experiences (ACEs) Victimized or witnessed abuse Verbal Sexual Physical Exposures Incarceration Homelessness Household instability – divorce, separation, death Mental illness or maternal depression Substance abuse (Poverty) (Racism)

4. Frequency of Exposure within Households to Adverse Childhood Experiences: BRFSS Results from 5 States(AR, TN, LA, WA, NM) # Aces % MMWR 2010; 59:1609

5. Frequency of Exposure within Households to Adverse Childhood Experiences: BRFSS Results from 5 States(AR, TN, LA, WA, NM) ExposurePrevalence Substance abuse 29.1% Separation/divorce 26.6% Verbal abuse 25.9% Mental illness 19.4% Witnessed violence 16.3% Physical abuse 14.8% Sexual abuse 12.2% Incarceration 7.2% MMWR 2010; 59:1609

6. Prevalence of Household Exposure to Adverse Childhood Experiences by Sex and Ethnicity Frequency of the number of ACEs does not differ substantially between men and women Specific ACEs do not differ substantially between men and women except for sexual abuse (6.7% vs 17.2%) and household mental illness (16.7% vs 22%) MMWR 2010; 59:1609

7. Number of ACEs by Educational Level in 5 States (AR, TN, LA, WA, NM) % MMWR 2010; 59:1609

8. Number of ACEs by Ethnicity in 5 States(AR, TN, LA, WA, NM) # ACEs % MMWR 2010; 59:1609

9. Transgenerational Transmission of ACEsSayer et al. NEJM 2014;371:1273

10. Abusive Abused Drug Abuse EtOH Chronic disease Mental illness Transgenerational Transmission of ACEsSayer et al. NEJM 2014;371:1273 Mental illness Abused Abusive Drug Abuse Chronic disease Suicidal EtOH Abusive Abused Drug abuse BMI 40 EtOH

11. Impact of ACEs Early Death Traumatic Experiences Felitti et al. Am J Prev Med 1998;14:245

12. Childhood Adversity and Metabolic Health Suglia SF et al. Circulation 2018;137:e15

13. Consequences of Exposure to ACES Smoking Illicit drug use Adult alcohol abuse Sexually transmitted diseases Unintended pregnancy School dropout Incarceration Attempted suicide Depression Chronic diseases - severe obesity, CVD, T2DM

14. Child Characteristics Related to ACEs ExposuresNational Survey of Child Health (n=96,000) Characteristic0 Aces1 ACE2 Aces Chronic condition 15% 20% 32% Overweight/obesity 26% 31% 39% Resilience 72% 63% 55% Repeated grade 6% 9% 15% Medical home 61% 50% 43% Mother’s health + 68% 49% 36% Bethell CD et al. Health Affairs 2014; 33:12 .

15. Programmatic Strategies to Build Individual Resilience Home visiting Parental training Social support for parents Parental support for adolescents Treatment for substance abuse High quality child care

16. Definitions Individual resilience: capability to anticipate and adapt successfully to challenges Community resilience: sustained ability of a community to prepare for, withstand, and recover from adversity In both cases, the question is not “What’s wrong with you” but “What’s happened to you”

17. Social Determinants of Health Healthy People 2020

18. Ellis WE, Dietz WH. Academic Pediatrics 2017; 17:S86

19. Disparities are the measure of inequities Health equity is a process and also an outcome. That outcome is achieved when health disparities no longer exist

20. Community Resilience Networked Capacities *Source: Norris, et al. (2007) Bouncing Back & Bouncing Forward

21. Buffers to Support Resilience Building Buffers Requires Multi-Sector Collaboration

22. Fostering Resilient Communities Equitable Opportunity Shift norm around conflict resolution Economic empowerment Workforce development Community mobilization and development Adverse Community Experiences and Resilience Prevention Institute 2015

23. Limited Opportunities Adverse Economic and Educational Environment Adverse Community Environments (Prevention Institute 2015) Intergenerational poverty Unemployment Limited jobs

24. Wealth building efforts Employment Job training Equitable Opportunity Economic and Educational Environment Supportive Community Environments

25. Economic development Educational parity Jobs Improved Social And Economic Resources Equitable Community Environments

26. Fostering Resilient Communities People Foster political and social engagement Strengthen social norms that encourage healthy behavior and social connectedness Organize community activities Change the narrative Adverse Community Experiences and Resilience Prevention Institute 2015

27. Limited Opportunities Adverse Economic and Educational Environment Adverse Community Environments (Prevention Institute 2015) Disconnected networks Low collective efficacy Low political efficacy Incarceration Intergenerational poverty Unemployment Limited jobs People Socio-cultural Environment

28. Wealth building efforts Employment Job training Equitable Opportunities Economic and Educational Environment Supportive Community Environments Connected networks Collective efficacy Political efficacy People Socio-cultural Environment

29. Economic development Educational parity Jobs Improved Social And Economic Resources Equitable Community Environments Empowerment Partnerships Healthy behaviors Build Community Capacity

30. Fostering Resilient Communities Place Improve quality of the built environment Invest in parks, housing, and transportation Reclaim, improve, and ensure safe public spaces Adverse Community Experiences and Resilience Prevention Institute 2015

31. Limited Opportunities Adverse Economic and Educational Environment Adverse Community Environments (Prevention Institute 2015) Disconnected networks Low collective efficacy Low political efficacy Incarceration Intergenerational poverty Unemployment Limited jobs People Socio-cultural Environment Place Physical/built Environment Deteriorated housing Dangerous public spaces Unhealthy products

32. Wealth building efforts Employment Job training Equitable Opportunities Positive Economic and Educational Environment Supportive Community Environments Connected networks Collective efficacy Political efficacy People Socio-cultural Environment Place Physical/built Environment Desirable housing Safe public spaces Healthy products

33. Economic development Educational parity Jobs Improve Social And Economic Resources Equitable Community Environments Empowerment Strategic partnerships Healthy behaviors Build Community Capacity Increase Healthy options Food retail Housing Built environment

34. Equity Framework for Integrated Clinical and Community Systems of Care Training &Education Family & Individual Empowerment and Engagement • Care Delivery • Information Systems • Decision Support • Delivery System Design • Self Management Support • Local patient environment • Clinicians • Community • Systems • Economic Resource • Social resources • Community capacity • Healthy options • Social norms Integration Convener, Advocacy, Data Exchange, Financing, Governance/Regulation, Referral Processes, Communications Population Health Metrics

35. Benefits of an Integrated System Activated people and patients – shared decision making Fosters increased investment in upstream determinants of health Buttresses value-based care Improves outcomes and reduces costs Advocacy - improved community services and resources

36. Steps to Building Community Resilience Identification of an integrator or anchor institution Trust Collaboration Community engagement Common goals Agreement on metrics to assess progress Sustainability

37. Trust Change moves at the speed of trust Trust moves at the speed of relationships Gary Gunderson, Personal Communication

38. Steps to Building Community Resilience Identification of an integrator or anchor institution Trust Collaboration Community engagement Common goals Agreement on metrics to assess progress Sustainability

39. Provider Capacity/Capability • System Capacity/Capability • Policy Supports • ACEs • Resilience • Narratives of the community Shared Understanding State of Readiness Engaged Families & Community Cross-Sector Partners • How to connect • Resource distribution • Community & Political Partnerships • Collaboration • Organizational linkages • Citizen Leadership • Social supports • Attachment to place Building Community Resilience: Process of Assessment, Readiness, Implementation & Sustainability

40. MO-Kan Oregon Cincinnati, Washington, Dallas The Building Community Resilience Network

41. Examples from the BCR Teams Washington DC – Local and national policy engagement Cincinnati – Parenting specialists placed in pediatric practices MoKan – Community councils Dallas – Family University Oregon – Leadership by the state’s largest provider of mental and behavioral healthcare for children

42. BCR Tools: Making Change Happen Coalition Building Identify Community Resources Shared Understanding & Language Identify and Connect New Partners Advocacy for Practice and Policy Change Pair of ACEs Health Care Systems Faith-Based Organizations Parents Local Funders Justice System Education

43. BCR Guide BCR Key Terms and Concepts Visualizing the Issue Buffers to Build Resilience BCR Example Stories and Scenarios BCR Talking Points BCR Communication Guidelines for the ‘Pair of ACEs’ Download the tools at go.gwu.edu/BCR

44. Policy & Advocacy

45. Challenges Trust Personal and organizational humility How do we assure that what we do heals families without causing further damage? How do we frame community initiatives that address adverse community environments without further stigmatizing communities? How do we assure that ACEs/toxic stress are perceived as a universal problem? Can we successfully treat the obesity or other consequences of ACEs without addressing ACEs, or the pair of ACEs? In a way that people see themselves in the workPersonal and organizational