Understanding and Addressing Childhood Adversity in California Department of Health Care Services

1. Understanding and Addressing Childhood Adversity in California Department of Health Care Services Learning Series May 10, 2018 Steve Wirtz Department of Public Health Injury Surveillance and Epidemiology Lori Turk-Bicakci Lucile Packard Foundation for Children’s Health Kidsdata Program

2. Agenda ACEs Fundamentals State-Wide Initiatives Data in Action

3. Science of Child Development: Impact of Childhood Adversity • Expanded Recognition of Social Determinants of Health • Communities, Systems & Organizations • Historical and Generational trauma • The CDC-Kaiser Permanente ACE Study • Initial Focus on Family Dysfunction • Health Consequences • Prevalence and consequences of adverse childhood experiences • Resilience, Research and Communities • ACEs Connection • Building a Resilient Trauma Informed California • Brain Science and Child Development • Life Course Perspective: Developmental and Socio-Ecological Framework • Architecture of the Brain • Neurobiology of Toxic Stress – “Get Under the Skin”

4. The ACE Pyramid - Mechanisms by which Adverse Childhood Experiences Influence Health and Well-Being Throughout the Lifespan Felitti, V. & Anda, RF The Relationship of Adverse Childhood Experiences to Adult Health Status A Collaborative effort of Kaiser Permanente and The Center for Disease Control http://www.cdc.gov/ace/ Slide Courtesy of Rob Anda, MD, MS

5. Original Adverse Childhood Experiences Source: CA BRFSS 2011-13 ACEs Module

6. As the number of ACEs increases so does the risk for multiple negative outcomes: • Ischemic heart disease • Liver disease • Chronic obstructive pulmonary disease • Alcoholism and alcohol abuse • Illicit drug use • Early initiation of smoking • Smoking • Poor academic achievement • Depression • Poor work performance • Financial stress • Health-related quality of life • Suicide attempts • Multiple sexual partners • Early initiation of sexual activity • Unintended pregnancies • Adolescent pregnancy • Fetal death • Sexually transmitted diseases • Risk for sexual violence • Risk for intimate partner violence

7. Summary of ACES literature Extreme traumas tend to cluster together to produce cumulative impacts Poverty increases the negative impacts of trauma Prevention and recovery are possible Childhood trauma is common • Social emotional impairment • Unhealthy behaviors • Mental problems • Physical health problems • Chronic diseases Consistent health impacts across multiple domains

8. Growing Body of Scientific Knowledge Early Childhood Investments Substantially Boost Adult Health Science 28 March 2014

9. Broader Context of Prevention • Developmental • Across life experiences (i.e., gestation, early childhood, adolescence, young adulthood, midlife, senior) • Across generations Life Course Perspective emphasizes a temporal and social perspective on health and well being: • Socio-ecological • Experiences are shaped by the wider social, economic and cultural context.

10. Understanding social disadvantage and impact on health across the life course and across generations SOCIETY INDIVIDUAL Social position by race & class 2.Differential exposure Social Context 1. Social stratification Influencing social stratification Decreasing exposures 3. Differential vulnerability Specific exposure Decreasing vulnerability 4. Differential consequences Disease Preventing unequal consequences Policy Context Social consequences of ill health 5. Further social stratification Adapted from Finn Diderichsen, U. Copenhagen Slide Courtesy of Paula Braveman

11. Poverty Rate by Age and Race, California Source: American Community Survey, 3-year estimates, 2011 Produced by: Center for the Next Generation, Prosperity Threatened Brief, January 6, 2013

12. Life Expectancy at Birth in California • A 15.3 year gap separates the CA areas with the longest life expectancy from the shortest: • 88.1 years – Orange (Newport Beach/Laguna Hills) • 72.8 years - Los Angeles (Watts) • Life expectancy at birth in San Francisco metro area ranges from: • 85 years in San Mateo (Burlingame & Milbrae) to • 74 in Oakland (Elmhurst) - an 11‐year gap within the same metro area.

14. Racing ACEs - If It’s not Racially Just, It’s not Trauma-Informed RYSE Center, Richmond CA Adverse Childhood Experiences* Historical Trauma • Trauma is historical, structural, and political. • The science has finally caught up. • Impacts of trauma are embodied across generations. • Differentiated Response: • White communities are validated, empathized, resourced restored. • Communities of color are shamed, questioned, ignored, stigmatized, criminalized. Consequences “Racism is (whites’) massive experience of cognitive dissonance.” – Dr. Joy deGruy Trauma and Social Location RYSE works to ensure primacy of the priorities, needs, and interests of young people of color across all practices, policies, approaches, investments, and relationships. • We lead with love and sacred rage • We prioritize people over programs • We acknowledge injustice and harm • We take risks • We stop to acknowledge loss and grief • We encourage self-care • We practice collective healing • We honor resilience and resistance • We celebrate and have fun

15. Social Production of Inequities String of Hazardous Land Use Divestment in Urban Code Redlining Interstate Highway System Foreclosure Crisis Suburban Investment Segregation Slide from Prevention Institute, Oakland CA

16. Public Health Perspective • Population based • Focus on social determinants of health • Comprehensive and systems orientation • Primary prevention priority • Data informed (i.e., best available research, experiential and contextual evidence) • Collaborative involving multiple sectors • Promotes equity and social justice • Large scale social change requires broad cross sector coordination • Not enough to have isolated interventions of individual organizations

17. State-Wide Initiatives

18. California Essentials for Childhood Common Agenda • Vision: All California children, youth and their families thrive in Safe, Stable, Nurturing Relationships and Environments • Mission/Purpose: To develop a common agenda across multiple agencies and stakeholders to align activities, programs, policies and funding so that all California children, youth and families have safe, stable, nurturing relationships and environments • Strategic Direction: Strengthen families and communities capacities to create safe, stable, nurturing relationships and environments for children

19. CA Essentials Backbone Organizations • Safe and Active Communities Branch, California Department of Public Health • Office of Child Abuse Prevention, California Department of Social Services

20. Partners & Initiatives

21. Collective Impact Approach • All working toward the same goal and measuring the same things • Cross-sector alignment • Organizations actively coordinating their action and sharing lessons learned • To achieve positive and consistent progress at scale • Collective Impact Overview Isolated Impact Collective Impact

22. CA Essentials Common Agenda • Challenges and Opportunities • Multiple well-established organization and efforts • Services: CBCAP; Home visitation (NFP, HFA); First Five, Commissions; Family Resource Centers • Policy: Children Now; Early Edge; First Five; Latino Health Coalition; Policy Link; Prevention Institute; Raising of America • Multiple frameworks and languages • SSNR&Es; Strengthening families; Family decision matrix • Child care competences, etc. • Develop matrix of common components & languages • Strive for “Mutually Reinforcing Activities”

23. EfC Aligned Activities Communications and Community Engagement/Public Awareness • ACEs awareness • Raising of America screenings, trainings and DVD Distribution • Community in Unity, Office of Child Abuse Prevention • Initiative to Build a Resilient, Trauma Informed State Partner Policy Initiatives • ACEs legislative resolution & Trauma Education and Screening • Disparities in school suspensions legislation • Early childhood education legislation • Family friendly work policies (paid family leave) • Economic supports (Earned Income Tax Credit) Programmatic • OCAP strategic initiatives and grants Data • ACEs prevalence (BRFSS; Hidden Crisis) • Child Adversity and Resilience topic - Kidsdata.org • County EfC data dashboards • Translating data into actionable information (e.g., local trainings)

24. Shared Data and Outcomes Workgroup • Childhood Adversity and Resilience topic link on kidsdata.org: http://www.kidsdata.org/topic/95/childhood-adversity-and-resilience/summary • California & County dashboards – www.kidsdata.org • ACEs training with Essentials for Childhood, Berkeley Media Studies Group, ACEs Connection, First 5, Kidsdata: Butte County training on 5/16/2017; Next training in Alameda County on 12/5/2017 • ACES Connection: https://acesconnection.shinyapps.io/sacramento_app/

25. OCAP Aligned Program Initiatives Create Healthier More Equitable Communities Strategies 2.0 Trainings Collective Impact Grants Innovative Partnership Grants Economic Empowerment Grants Collaborative Initiatives within CDSS (e.g., CalWorks; EITC)

26. OCAP Aligned Initiatives Child Abuse Prevention Month Campaign “Community in Unity” (Collaboration, Connectedness and Shared Responsibility) Parent Leadership Campaign (e.g., Lead4Tomorrow) Paper Tigers Screenings Framework for Trauma-Informed Systems

27. Initiative to Build a Resilient Trauma-Informed California To conduct outreach to existing (known) partners and survey them to collect and share information on their current TI activities. To conduct outreach to existing (known) partners and survey them to collect and share information on their current TI activities. To promote the multiple existing efforts and guide the development of trauma-informed policies and practices that incorporate an asset-based (i.e., strength/resiliency) approach within and across California communities, systems, organizations and workforces.

29. ACEs Connection Network A Community member's response to starting a new community on ACEs Connection and learning about the tools: Can we put data into the ACEs presentation tracker? I've been playing around with the [ACEs Connection] site. It is awesome! How soon can we go live with it? Organizations that Have Received an ACEs Science Presentation http://www.acesconnection.com/g/sonoma-county-aces-connection

30. Engages communities, systems and organizations in a culture change, emphasizing core values of safety, trustworthiness, choice, collaboration, and empowerment in every facet of the environmental and policy context, program activities, physical settings, and relationships. Trauma-Informed Approach • Requires a multi-pronged, multi-system, multi-agency approach • Public education and awareness • Community engagement and social norms change • Systems and policy change • Prevention and early identification • Effective trauma-specific assessment and treatment • An organizational or community systemic approach includes a “trauma-informed” environment capable of sustaining trauma-specific services and supporting the positive outcomes to clients who receive these services.

31. Data in Action Data about childhood adversity dashboards Access to Data

32. Kidsdata.org High-quality, wide-ranging, local data 55+ Topics By Regions By Demographics 600+ Indicators 50+ Data Sources Context & Recommendations

33. Social Determinants of Health Economic Stability Education System Health Care Improved Health and Well-Being Community Environment Source: Adapted from Healthy People 2020

34. Data about childhood adversity Data Partners California Essentials for Childhood Initiative, California Department of Public Health Population Reference Bureau (NSCH data) California Department of Public Health’s Maternal, Child and Adolescent Health Program and the University of California, San Francisco’s Center on Social Disparities in Health (MIHA data) CDPH/Public Health Institute’s Survey Research Group (BRFSS data)

35. Data Sources National Survey of Children’s Health (NSCH) Behavioral Risk Factor Surveillance System (BRFSS) Maternal and Infant Health Assessment (MIHA) Family, economic, and community measures Family, economic, and community measures Family measures Adults reflected on own childhood experiences Parents reported on child’s experiences Post-partum mothers reported on own childhood experiences

36. Data Types

37. Dashboards

38. Access to Data

40. Sign Up Kidsdata.org/MyEmails

41. Thank you! Steve Wirtz Department of Public Health Injury Surveillance and Epidemiology Steve.Wirtz@cdph.ca.gov Lori Turk-Bicakci Lucile Packard Foundation for Children’s Health Kidsdata Program Lori.Turk@lpfch.org