Ace Train the Trainer Presentation


Published on

Published in: Education, Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Welcome participants and thank them for coming. Explain overall goals of the presentation, any “housekeeping” details.   History behind presentation: The ACE movement in Arizona has been spearheaded by Phoenix Children’s Hospital (PCH) and began in 2006 when PCH brought Dr. Felitti to Phoenix to educate physicians, legislators and other community leaders. In 2007 a small think tank was formed to brainstorm ways to spread the word about the impact of childhood trauma. As more members came on board it was decided more needed to be done and the Arizona ACE Consortium was formed. This presentation was rolled out statewide in April 2010. Two TV specials on ACE’s and a website was launched. Today the think tank has evolved into a state wide group called the ACE Consortium with over a hundred members.
  • Slide 2 – This quote from Margaret Mead sums up the presentation. What happens when one is growing up impacts adult health and behavioral outcomes. In other words: Society reaps what it sows in nurturing children.  
  • Slide 3- What are ACES?
  • Slide 4 – Be sure to highlight this slide. It is important for participants to know that there are things that can be done to mediate impact of ACEs. Just talking with a caring, nurturing person about your experiences can have a positive impact. Acts of kindness can go a long way. Learning new behaviors - ways to cope and parenting skills - can break the cycle.
  • Slide 5 - Ask audience by a show of hands to rate their awareness of the ACE Study. Next distribute the ACE questionnaire. This survey is a condensed version of the actual research tool used.
  •   Slide 6 – Ask participants to fill out the ACE Study (or calculate in their head) if they are comfortable doing so . Reassure them they will not be asked to share their score – it’s just to get a better understanding of the categories of ACEs. Invite comments on the questionnaire. This tool was used in the study to assess the relationship between ACE score and adult health and social problems.
  • Slides 7 & 8 - There are 2 general categories: child maltreatment and family/household dysfunction.   Note: If you have the ability, consider showing the PBS Horizon interview with Dr. Felitti. Link to the study: . Video is 10 minutes long and provides a nice introduction to the ACE study.  
  • Slides 8-9 - There are 2 general categories: child maltreatment and family/household dysfunction.   Note: If you have the ability, consider showing the PBS Horizon interview with Dr. Felitti. Link to the study: . Video is 10 minutes long and provides a nice introduction to the ACE study.
  • Slide 10 – Some of the key outcomes discovered were how common ACE’s are with 2/3’s participants having at least one ACE. As the ACE score increases so does the risk of numerous health and social problems throughout life. These health and social problems are not randomly distributed across the population. For example: Addictions are highly correlated to experiences in childhood; 97% of adult alcoholics had history of ACE’s. In other words, stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality.
  • Slide 11-Allow your audience a chance to think about ACEs in their own community and observations they may have on how it manifests.
  • Slide 10 - 14 – The ACE study is a decade-long and ongoing study designed to examine the childhood origins of many of our nation’s leading health and social problems. The study was conducted in collaboration with Centers for Disease Control and Prevention and Kaiser Health Plan’s Department of Preventive Medicine in San Diego, CA.   Adverse Childhood Experiences (ACE’s) are negative experiences or events children are exposed to within their family/household. These common stressful or traumatic events affect (neuro) development in children. Stress that the ACE Study is: Unique because it looked at the relationship of a broad range of ACE’s to a wide range of health consequences. Most previous studies looked at the impact of a single issue. For example: impact of domestic violence or the impact of sexual abuse. Largest study of it’s kind ever done; over 17,000 participants Solidly middle class (employed, with health insurance); average age of 57 Over 75% had some college or were college graduates More than 1 in 10 participants had an ACE score of 5 or more   *** If there are questions about specifics (race, age, gender, etc) refer them to the website ( ) or for all research details.
  • Slide 14: The name of Dr. Felititi’s 2002 journal article. In the article about the ACE study, he refers to this process of traumatic emotional experiences of childhood turning into organic adulthood disease as a “reverse alchemy.” These images of the newborn infant (gold) developing into the (lead) of a diseased or depressed individual underscore the powerful implications of the ACE study.
  • Slide 15 thru 18 - 1/3 of the people in the study had an ACE score of 0; however that means that 2/3 have an ACE score of 1 or more. High ACE scores are not uncommon: 25% had ACE score of 1 15% had ACE score of 2 10% had ACE score of 3 6% had ACE score of 4 11% had ACE score of 5 or more (one in ten) 67% of all adults experienced at least one category of ACE Women are 50% more likely to have ACE score greater than 5 Someone with 5 or more ACE’s is 5000 times more likely to attempt suicide.  
  • Slide 18 – The key findings of the study are that stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality.
  • Slide 19- Taking a closer look at AZ Data, we can see a similar breakdown as the original ACE study.
  • Dandelions are common are so are ACEs.
  • Slide 21- This may be a good time to allow the audience to consider
  • These ratios are based on the original data. This slide highlights the assertion that chronic diseases occur as a result of high risk behaviors often initiated in adolescence.
  • Slide 23- Throughout this presentation, please take time to highlight slides that simply offer hope and healing in the face of adversity. It might be helpful here to remind the audience that even though talking about the ACE study can be sad, this workshop also offers solutions and stories of resiliency.
  • Slide 24- ACE’s are highly interrelated and commonly occur in clusters. If any ACE is present, there is an 87% chance at least one other category of ACE is present. ACE’s are so interrelated that trying to determine the impact of one ACE does not make sense.
  • Slide 25- Very much like the spread of a virus, without an interruption or an intervention, ACEs will spread.
  • Slide 26- This chart shows the interrelationship if a parent was an alcoholic and is then more likely to have experienced other categories of ACE’s.
  • Slide 27- The key findings of the study are that stressful or traumatic experiences lead to increased risk of unhealthy behaviors, risk of violence or re-victimization, disease, disabilities and premature mortality.
  • Slide 30 – Chronic diseases occur as a result of high-risk behaviors often initiated in adolescence when teens begin to develop more independence
  • Slide 29- Adverse Childhood Experiences determine the likelihood of the ten most common causes of death in the US. Many of the issues we don’t make progress on have their roots in ACE’s. Additionally, ACE’s have a strong influence on teen pregnancy, early alcohol use, drug use, stability of relationships, performance in the workforce, and an increase risk of being re-victimized.
  • Slides 30-31 : Chronic diseases occur as a result of high-risk behaviors often initiated in adolescence when teens begin to develop more independence.
  • Slide 32-34 - Negative behaviors are functional for the person. They help the person survive and move forward. Even though the behaviors may be destructive and damaging, they also may be effective in helping people function. Point out that these coping strategies are solutions that almost work. More effective coping strategies will be suggested at the end of the presentation. Dr. Felitti quote: “It is hard to get enough of something that almost works.”
  • Slide 36- Using sexual abuse as an example, the pyramid helps to visualize the process by which harsh experiences such as abuse, neglect, and loss of birth parent(s) during childhood result in health problems in adulthood.  
  • Credit Jim
  • Slide 43 – Brain scan of child in Romanian orphanage. The red areas indicate brain activity. As you can see the majority of the activity is in the back near the brain stem the survival part of the brain.
  • Slide 47 – The human brain is wired for survival and will use all its energy to survive when under stress. Trauma during the first five years has the biggest impact on the brain because the brain forms the greatest number of connections at this time.   Has anyone had an experience where they have been under a great deal of stress and then things start to happen which ends up causing more stress? Like you drop something, forget to do something, or can’t remember something. The brain is using its energy to manage the stress so other parts are not working as well.  
  • Slide 48 – Technology has opened many discoveries on how the brain develops and works. We know that everyone is born with brain architecture – all the neurons are in place but they have not all connected to each other. The majority of these connections happen in the first four years of life but the brain is still forming connections into the early twenties. Through interactions the neurons begin to form these vital connections. For example: The connections for language are formed as the infant hears people speak to him.   The early years of life matter because they affect the architecture of the maturing brain. The quality of that architecture establishes either a resilient or a fragile foundation for all of the development and behavior that follows.
  • Slide 51- As children become teenagers they are much more independent and are searching for a way to cope. This is when many turn to some of these almost successful ways. The likelihood a teen will begin drinking alcohol at age14 dramatically increases with each ACE.  
  • Slide 52 – When you look at the iceberg you cannot see what is under the surface, but you know something is there. Behavior is the same way. You see the actual behavior but what we don’t see is what is driving that behavior. What happened first to cause it? Is the behavior a way for the person to cope? Are they coping the best they can?
  • Slide 53 - When under stress the body is in a more heightened arousal – heart rate goes up; blood pressure may rise, breathing increases. For example: If you were all alone at night walking down a dark street you may startle at a small sound like a breaking stick. If it occurred during daylight and your stress level was lower, you may not hear it. Repeated stress can wire your brain to function at a higher arousal level which will take a toll on your physical health.   When our “survival” brain is in charge, we impulsively react with defensive behaviors. These limited behaviors are primarily shaped by old patterns based on past experiences that have caused pain or fear. When the “survival” brain is in charge a person may react aggressively, fight and refuse to cooperate, throw a temper tantrum, etc.. They could also go the opposite direction and withdraw, space-out, be unable to assert self or become overly compliant and always trying to please everyone.
  • Slide 61- Given the research emerging on essential role of early caregiver-child relationships on lifelong health, Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative David Willis proposed a “4 th Vital Sign”. Adding this fourth vital sign places the spotlight on early relationships in pediatric assessments.
  • Slide 64 - The following several slides are graphs visually showing the increasing correlation between the number of ACE scores (along the bottom from left [1] to right [6]) and the % of people engaging in the risky behaviors (vertically from 0% at the bottom to 100% at the very top).   Note: Even 6 or more ACEs does not automatically mean a person will engage in the risky behavior or have the adult chronic disease, but the % of those with high ACE scores who also engage in the behavior or have the disease/condition is increased.   Note: These can be run through fairly quickly.   This first graph depicts the relationship between ACE’s and smoking. As the number of ACE’s goes up, so does the probability the person will smoke. Smoking is the leading cause of preventable death in the United States. Smoking leads to chronic obstructive pulmonary diseases which is one of the top ten causes of death in US.
  • Slide 65 – Not only does alcoholism negatively impact the adult alcoholic, it will impact their children as well. In fact, children of alcoholics are more likely to experience additional ACE’s.  
  •   Slide 66-67 ACE’s appears to be a hidden “engine” underlying the transmission of HIV. We know that injected drug use and promiscuity (50 or more lifetime intercourse partners) are risk factors for transmission of HIV.
  • Slide 68 - Red = unintended pregnancy - Yellow = elective abortion.
  • Slide 69 - Females are red; males are yellow. Chronic depression is the leading cause of disability worldwide. Antidepressants are the most rapidly increasing prescribed drug.
  •   Slide 70 – An individual with an ACE score of 4 is 12 times more likely to attempt suicide than those with none. There seems to be two peak times when people are more likely to attempt suicide – adolescence and middle age.
  • Slide 71 – ACE’s are costly to the workforce. Recent estimates indicate the annual cost to the US workforce is $28 billion for chronic back pain, $30-44 billion for depression and related absenteeism, reduced productivity and medical expenses, and $246 billion for chemical dependency.   Conclude the slides with: As you can see the higher the number of ACEs, the greater the risk. In fact an ACE score of 6 or more may result in as much as a 20 year decrease in life expectancy. This consistent pattern of increase is almost unheard of in medical studies.
  • Slide 73 – Chronic diseases, many of which have risk factors related to ACEs, have a large cost on our system.
  • Slide 74 – ACE’s are likely to be invisible to healthcare providers, educators and policy makers. The study discovered that just asking about ACE’s reduced physical symptoms in patients for up to two years. By asking about ACE’s healthcare providers can use a more integrated approach instead of just treating the symptom. Gathering this information improves treatment.
  • Slide 75 – Pay Now or Pay Later
  • Slide 76 Our Challenge - If able to access YouTube, consider showing this video on ways you can change young children’s lives. “Change the First Five Years and You Change Everything”, 4 min.
  •   Slide 78 – By this point we hope we have motivated you to do something differently. The second half of this presentation focuses on specific ways each of you can positively impact your community. I urge you to think about which one of these strategies you are willing to do. If all of us leave this room today and begin implementing some of the recommended strategies, we can begin to build a stronger community and positively impact the lives of many Arizonans to ensure a better future for all.
  • Slide 79 – Part 2 Caring Communities Starts Here – for this section you may want to add or delete slides to adapt to your audience. Believe that caring communities can help reduce ACE’s. If you have a story of a child or family that overcame adversity you may want to share it here. Be sure to highlight the community protective factors that helped this person move forward.
  • Slide 80 - Believe that caring communities can help reduce ACE’s. If you have a story of a child or family that overcame adversity you may want to share it here. Be sure to highlight the community protective factors that helped this person move forward.
  • Created in partnership with development teams at Arizona State University Judy Krysik and tested in Florida schools during the 2010-2011 school-year, the new Childhelp Speak Up Be Safe™ curriculum, materials and training capsules are currently being launched to schools throughout the country for the upcoming fall semester. Childhelp Speak Up Be Safe , the evolution of Good-Touch Bad-Touch ® , offers a 21st century approach to the prevention of abuse by utilizing web-based tools, curriculum on Internet safety skills and cyber-bullying and a redirected focus on adult responsibility and skill building in keeping our children safe.
  • Slide 82- An excellent video clip to show here is “Change the First Five Years and You Change Everything”. The clip is 4 minutes long and helps the audience understand ways they can change the lives of young children.
  • Slide 46 – 49 – Briefly mention 3 important concepts – protective factors, resilience and trauma-informed care - that will be covered in 2 nd half.
  •   Slide 84 – You have already started by taking part in this training – you are increasing your understanding of the importance of protective factors. By using protective factors in your own life you are modeling for your children and others you work and play with. As you come across others you can help by educating them and encouraging them to utilize protective factors.
  • According to the US Department of Health and Human Services Office of Women’s Health, 85-95% of women in the public mental health system report a history of trauma. When programs and/or individual service providers shift from a “what’s wrong with you?” approach to “what happened to you?” they can reduce the likelihood that an individual will be harmed by an unintentional recreation of the abuse. Likewise, a trauma informed approach may enhance client engagement, avoid staff burnout, and improve the quality of services
  • Slide 94- Tonier Cain is a national speaker and consumer advocate that speaks on the importance of trauma informed care. Her first hand experiences with both risk and resiliency are an important part of seeing how the ACE study can inform the work we do. The
  • Slide 95 – For years researchers have been studying both risk factors and protective factors to determine what conditions help families under stress and reduce the incidence of child abuse and neglect. Some protective factors we have control over, and others we do not. We are going to look at the factors we can change.   Risk factors are conditions that have been shown through research to have a significant correlation with a negative behavior or outcomes such as substance abuse and behavioral health problems. They do not necessarily cause problems but they do show a correlation relationship. Protective factors are conditions that have been shown through research to reduce the likelihood of the undesired behavior or outcome. For example: One of the strongest protective factors for youth is having a close, caring relationship with an adult.  
  • Slide 96 – Research has shown the following six protective factors are linked to a lower incidence of child abuse and neglect. For the next several slides we are going to explore each of these protective factors including strategies that each of us can implement to increase protective factors in our communities.
  •   Slide 97 This is the number one protective factor. Often when adults talk or write about what helped them get through a really traumatic childhood, they refer to one or more persons that they were able to turn to – their go-to person. Every child needs an adult that will feed and protect them, support and encourage them, and educate them.
  • Slide 98 – Babies that receive affection and nurturing have the best opportunity of developing into happy, healthy and competent adults. When caregivers work to understand their needs and provide comfort, the child’s brain is positively affected. Children in a relationship with a consistent, caring adult in the early years are associated with better grades, healthier behaviors, more positive peer interactions and an increased ability to cope with stress later in life. As children grow older they become able to meet some of their basic needs. This is the time when children need someone who listens and discussions become vital.
  • Slide 99 – Babies that receive affection and nurturing have the best opportunity of developing into happy, healthy and competent adults. When caregivers work to understand their needs and provide comfort, the child’s brain is positively affected. Children in a relationship with a consistent, caring adult in the early years are associated with better grades, healthier behaviors, more positive peer interactions and an increased ability to cope with stress later in life. As children grow older they become able to meet some of their basic needs. This is the time when children need someone who listens and discussions become vital.
  •   Slide 100 – If you are an organization that works with either children or families these are things you could put into place to increase parent/child attachment. Set up an activity that brings families together like a family potluck, movie night, etc. Point out when you see adults nurturing their children. State specifically what the nurturing behavior is. Provide information. Be that caring adult to a child or help the child join an activity so that they have an opportunity to develop a caring relationship with an adult.  
  • Slide Let’s take a look at what a safe, stable and nurturing relationship looks like. Exercise: I want each of you to think about the person you turn to when you need support. What does the relationship look like? Who is this person? How does he/she make you feel? What are the things this person does that support you? After a couple of minutes have everyone turn to their neighbor and share what their go-to person does that supports them. Give participants about five minutes to complete this. Bring participants back and ask for examples of things their go-to person does that is supportive. The list generated are behaviors that each of us can implement with someone who may need a more supportive person in their lives.
  • Knowledge is power. Discipline is more effective and more nurturing when parents know how to set and enforce limits that meet the developmental needs of their children. Child abuse and neglect are often associated with a lack of understanding of basic child development or the ability to put knowledge into action.
  •   Slide 61 – When teaching anyone a new skill it is important to think about what the person currently knows and their goals. Setting a stage for learning is important. Is there a place parents can get information when needed? Do parents know where to look for information? Help prepare parents for the next stage in their child’s development by educating them on what comes next. Set up parenting classes or provide information on local classes. Encourage parents to attend.
  • ACE’s can reduce our capacity to cope effectively with typical day-to-day stress. It is important to look at inner strengths and build on them. Everyone has inner strengths – faith, flexibility, humor, communication skills, problem solving skills, caring relationships to name a few. Also look at what might be missing or weaker, and use strategies to strengthen these coping mechanisms. There are numerous community programs designed to strengthen resiliency – mental health services, counseling, AA, therapy, etc
  • Slide 105– Parents are models for their children. Children learn to cope by watching how their parents cope and manage stress. Increase your own resiliency by reaching out and helping others, develop trusting relationships – connect with others – learn to recognize your own early symptoms of stress.
  • Slide 106- This slide emphasizes the importance of resiliency as a buffer to serious life challenges. It may be important to highlight slides that reflect hope and healing throughout the presentation. Given the prevalence of ACEs it always important to consider providing this information in a way that is sensitive to the possibility of audience member with unresolved trauma.
  • Slide 66 – Help build resiliency in others by being supportive. Help them recognize early signs of stress and point them towards appropriate resources. Be a caring neighbor – by helping a neighbor you are not only building your own resiliency but theirs also.
  • Slide 109 Parents with a network of supportive family and friends may have an easier time caring for themselves and their children. On the other hand, research has shown that families living in isolation are at higher risk for abuse and neglect. Helping parents make connections with others by identifying resources (faith based, community centers, schools, etc) providing opportunities for parents to meet one another or simply supporting parents in their efforts to reach out is helping increase a very important protective factor in your community. In addition, parents supportive relationships can help model positive social interactions for young children while giving them access to other supportive adults.   Take a look at your community and think about ways to bring people together. Are there isolated groups within your community you want to target, like grandparents raising grandchildren? Sometime children need help developing friendships and social skills. They may be reluctant to participate in group activities and will need encouragement. Teach healthy coping skills through nutrition and exercise. Notice and support their efforts to connect to adults. The techniques or strategies children use to connect to adults may not always be positive.
  • Slide 109 – Many factors beyond the parent-child relationship affect a family’s care of children. Parents need basic resources to ensure the health and safety of their children. Some families need help in connecting to resources. Helping to connect families is critical. Teaching families to be their own advocate and learn skills like money management, job training, and preventive health care are critical.
  • Slide 110 – Children’s ability to interact with others is develops over time. For some children social skills comes easily while other children need numerous repetitions. As children increase their ability to relate to others and express their emotions, parent’s find them easier to manage. Children who do not respond to affection and nurturing from their parents are at a higher risk for abuse.
  •   Slide 111 – Use direct instruction through activities or a structured curriculum to teach social skills such as sharing, empathy, problem solving, respecting others, etc. Parents need to understand what is typical social/emotional development and how it impacts overall development. The earlier adults begin helping children with delays the easier it is to remediate concerns.
  • Slides 112-119 The following slides are an activity option for your presentation. The conversation starters (questions) are designed to help parents identify their strengths and reflect on how protective factors play a role in their lives.
  • Slide 119 – The Community Anti-drug Coalitions of America (CADCA) in Washington DC has developed a useful framework of seven strategies for communities. (At this time you may want to distribute the handout “Seven Strategies to Build Strong Communities”. There is a blank line for participants to write in their own ideas.) Each of these strategies can have a positive impact on a community. As we review these strategies think about techniques you would be willing to implement. In order for change to take place something different has to happen.
  •   Slide 77 – The first strategy is Provide Information to people. Included in this strategy are activities like giving someone a brochure, directing someone to a website, sharing information with a friend or co-worker on ACE’s, or hanging a poster in a grocery store. The goal is to increase public awareness. Provide information on child development, nurturing and attachment. Teaching others to look for signs and symptoms of child abuse and how to report.
  • Slide 121 – Enhancing skills is a little more than providing education. In this strategy the goal is to teach someone a new skill. This could be conducting a workshop on ACE’s, a parenting class, or building resilience in your own family by having regular family meals, teaching a child friendship-making skills or helping someone learn how to manage money.
  •   Slide 122 - Providing support is the third strategy. This can be as simple as contributing to community programs, volunteering, mentoring a child or family, or helping a neighbor who is overwhelmed.
  • Slide 123 – The fourth strategy, enhancing access/reducing barriers, involves techniques that increase the ease and ability for people to obtain resources and services. This could include starting local support groups, donating to a charity, or sharing information with others on where to obtain a needed service.
  • Slide 124 –Changing the consequences associated with a behavior can either reduce or increase a behavior. Recognizing someone for building a strong community may increase their behavior or cause someone else to do something positive in their community.
  • Slide 125 - There may be some type of physical/environmental change within your community that will reduce risk factors. For example, putting in lights in a park can make the park safer thus reducing risk. Cleaning a park may give families a place to relax and have fun together. Painting a home demonstrates that people do care.
  • Slide 126- Be an advocate for prevention. Know who you are voting for. Write your legislators.     Slide 85 - Close with “One caring adult can make a significant difference in the life of a child . . .”.
  • Slide 85 - Close with “One caring adult can make a significant difference in the life of a child . . .”.   Personal Commitment Exercise: Distribute the “7 Strategies to Build Strong Communities” handout and the Evaluation Form. This is also an opportunity to pass out a contact information sheet if people to complete if they want to be contacted or get involved with their Regional Child Abuse Prevention Council. Explain that the Personal Commitment Checklist is a summary of the last several slides with ideas of ways people can get involved to reduce ACEs, Build Strong Communities and Raise Strong Kids. Ask audience members to take 5 minutes to review the form and make a personal commitment to engage in at least one activity. Audience members keep their personal commitment forms. Answer questions. Ask audience to complete the evaluation form and collect them. Thank audience for their attendance, for sharing their creative ideas and for their commitment to helping ensure a positive future for children and their community
  • Slide 132 – Similar to the old saying “It takes a village to raise a child”.
  • Ace Train the Trainer Presentation

    1. 1. Strong Communities Raise Strong Kids Impetus for Community Action
    2. 2. “The solution of all adult problems tomorrow depends in large measure upon the way our children grow up today.” ~ Margaret Mead, Anthropologist
    3. 3. What Are ACEs? Adverse Childhood Experiences • Traumatic experiences in childhood • Sometimes referred to as toxic stress or childhood trauma
    4. 4. ACEs Often Last a Lifetime . . . But They Don’t Have To • Healing can occur • The cycle can be broken • Safe, stable, nurturing relationships heal parent and child
    5. 5. Quick Survey Rate Your Awareness of the ACE Study: - No Knowledge of ACE Research - Some Knowledge - More Than Most - Expert
    6. 6. Complete ACE Questionnaire • What does it make you think about? • Keep in mind your thoughts as we present the ACE Study
    7. 7. What Do ACEs Look Like?
    8. 8. Two Categories of ACEs 1) Growing up (prior to age 18) in a household with abuse: • Recurrent physical abuse • Recurrent emotional abuse • Sexual abuse • Emotional or physical neglect
    9. 9. Two Categories of ACEs, cont. 2) Growing up with 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.
    10. 10. Why is This Important? Because ACEs are: • Surprisingly common • Occur in clusters • Basis for common public health problems • Strong predictors of later social functioning, well-being, health risks, disease, and death
    11. 11. Question How do you see ACEs manifested in kids and families in your community?
    12. 12. How It All Started Watch Horizon interview Dr.Vincent Felitti Watch overview of ACE Study (DV
    13. 13. Arizona ACE Initiative
    14. 14. “Turning Gold into Lead”
    15. 15. Study Participants • 26,000 adults invited to participate; 17,337 accepted • Solidly middle class • Average age = 57 *Keep in mind there are ongoing studies. This demographic information is on the original study participants. See profiling 5 states that have collected data.
    16. 16. Demographics of participants
    17. 17. ACE Scores • 1/3 of adults have an 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 the US.
    18. 18. ACE Scores • Women are 50% more likely than men to have an ACE Score >5 • If any one ACE is present, there is 87% chance at least one other ACE is present, and a 50% chance of 3 others • This combination makes ACEs the leading determinant of the health and social well-being of our nation
    19. 19. Arizona Children 0 – 17 years (2011/2012 Natl. Survey of Children's Health) • 42.5 % - Zero ACEs • 26.4 % - One ACE • 31.1 % - 2 or more ACEs • National Average - 22.6% - 2 or more ACEs
    20. 20. ACEs are Common ACE Score Prevalence 0 33% 1 26% 2 16% 3 10% 4 or more 16%
    21. 21. Group Question: Do you think ACEs are common in your community? Why or why not?
    22. 22. With 0 ACEs 1 in 16 smokes 1 in 69 are alcoholic 1 in 480 use IV drugs 1 in 14 has heart isease 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 isease 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…
    23. 23. All the world is full of suffering, it is also full of overcoming. -Helen Keller
    24. 24. ACEs are Interrelated and have a Cumulative Stressor Effect It is the number of different categories, not the intensity/frequency of the ACEs that determine health outcomes.
    25. 25. ACEs are Interrelated and have a Cumulative Stressor Effect Without interruption, ACEs escalate across generations.
    26. 26. ACE’s are Highly Interrelated Alcohol Abuse in the Home and the Risk of Other Household Exposures During Childhood
    27. 27. • ACE score of 4 or more may result in multiple risk factors for these diseases or the disease themselves • ACE score of 6 or more may result in a 20 year decrease in life expectancy
    28. 28. Evidence Suggests • Many chronic diseases in adults are determined decades earlier by experiences in childhood. • Risk factors/behaviors for these diseases are initiated during childhood or adolescence and continue into adult life.
    29. 29. Top 10 Risk Factors for Death in USA smoking severe obesity physical inactivity depression suicide attempt alcoholism illicit drug use injected drug use 50+ sexual partners history of STD
    30. 30. Life Long 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.
    31. 31. Dr. David McCollum, retired ED physician and co-founder of the Academy on Violence & Abuse (organization aimed at health professionals - provides education and research on the effects of violence and abuse on health).
    32. 32. Coping Solutions • What are conventionally viewed as Public Health problems are often personal solutions to long concealed adverse childhood experiences.
    33. 33. Seeking to Cope • Risk factors/behaviors underlying adult diseases are effective coping devices. • Dismissing these coping devices as “bad habits” or “self destructive behavior” misses their functionality.
    34. 34. ACEs and Addiction “It’s hard to get enough of something that almost works.” Dr. Vincent Filetti ACE findings suggest that 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.
    35. 35. ACEs in the Classroom • ACEs are the greatest single predictor for health, attendance and behavior. • ACEs are the second strongest predictor, after special education status, for academic failure. • The relationship between academic achievement and health status appears much less related to income than to ACEs.
    36. 36. ACE Pyramid
    37. 37. Jim Sporleder of Lincoln High School tried a new approach with his students. Using a more trauma sensitive approach, Mr. Sporleder and staff changed the entire culture of the school. ACEs in Action!
    38. 38. “Pyramid of Hope” “Before we can get our students prepared for learning, we have to focus on their wounds and history of failures” Jim Sporleder (principal of Lincoln High School)
    39. 39. Design your own “Pyramid of Hope”
    40. 40. Brain Development • We are hard wired to survive. • Brain architecture is established early in life. • Healthy brain architecture is the necessary foundation required for optimal future learning, behavior and health.
    41. 41. 3 Core Concepts in Early Brain Development Harvard Center for The Developing Child
    42. 42. 1.) Experiences Build Brain Architecture Experiences Build Brain Architecture Clip
    43. 43. 2.) “Serve and Return” Interaction shapes brain circuitry. Nurturing, responsive, and individualized interactions from birth build healthy brain structure Serve and Return Clip
    44. 44. 3.) Toxic Stress derails healthy development Toxic Stress Clip
    45. 45. “Brain Hero” Brain Hero Clip Harvard Center for the Developing Child
    46. 46. Stress and the Brain Excessive and repeated stress: • Neglect, Violence • Chaos, unpredictability • Hostility, rejection Causes disruption of brain architecture: • Impairs cell growth • Interferes with healthy neural circuits • Strains brain with overdose of stress hormones
    47. 47. • Causes children to live in fight, flight or fright (freeze) mode. • 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, shame and frustration Toxic Stress can impact children in the following ways:
    48. 48. “It is fact not opinion that “Toxic Stress/ACE’s” has a severe impact on the brain development and a person’s future. It is a strong predictor with negative outcomes without the intervention of a positive adult relationship(s).” Jim Sporleder • Respond • Learn • Process effectively
    49. 49. Having a hard time with my feelings Having a hard time with my feelings Calming down, but not quite calm enough yet. I think I am ready to learn. Visual tool used by Principal Jim Sporleder to help his students identify when they are ready to talk or to learn.
    50. 50. By adolescence, children seek relief through: • Drinking alcohol* • Smoking tobacco • Sexual promiscuity • Using drugs* • Overeating/eating disorders • Delinquent behavior, violence • High-risk sports, etc. * Note: nicotine and methamphetamines are anti-depressants
    51. 51. All behavior (both good and bad) has meaning We need to ask ourselves what might be going on going on beneath the surface.
    52. 52. What Does This Look Like? Teen that is: – Edgy, hot tempered – Impulsive – Hyper-vigilant
    53. 53. Or some teens may be withdrawn, feel anxious/depressed, have somatic complaints and/or isolate.
    54. 54. High Risk Teen Behaviors • May not be the core problem • They may be coping devices • A way to feel safe or just feel better
    55. 55. Traumatic Stress Responses Trauma is complex and reactions are different for everyone. “Children can exhibit a wide range of reactions to trauma and loss.” ***Factors such as the child’s prior history of trauma, temperament, expectations of danger, vulnerability, relocations, and coping resources of the family play a role in traumatic stress responses. National Center for Child Traumatic Stress
    56. 56. What Can this Look Like? • Changes in eating or sleeping routines • Changes in growth and development • Changes in relationships • Regressions in developmental abilities
    57. 57. Complex Trauma “Complex trauma describes both children’s exposure to multiple traumatic events and the wide-ranging, long-term impact of this exposure.” – Events such as abuse or profound neglect – Children may develop ways of coping that allow them to survive on a day to day basis (like hiding emotions or being overly sensitive to the moods/behaviors of adults) – These kinds of learned adaptations make sense in the context of constant physical and/or emotional threats. – However as the child grows and encounters safe situations or relationships, these adaptations may interfere with their capacity to love and be loved. National Child Traumatic Stress Network
    58. 58. Possible Reactions of Children 0-6 Exposed to Traumatic Stress National Child Traumatic Stress Network • Excessive temper • Regressive behaviors • Scream or cry excessively • Startle • Anxious, fearful or avoidant • Fear of separation • Irritability • Poor sleep/nightmares • Poor appetite, low weight or other digestive problems
    59. 59. Possible Reactions of Older Children Exposed to Traumatic Stress Children ages 6-12 may: • Have difficulty paying attention • Become quiet, upset, and withdrawn • Be tearful, sad and talk about scary feelings and ideas • Fight with peers or adults • Show changes in school performance • Want to be left alone • Eat more or less than usual • Get into trouble at home or school
    60. 60. The 4th Vital Sign Respiration, heart rate, blood pressure and relationships To heal, children need recognition and understanding from their caregivers
    61. 61. Break 
    62. 62. ACEs don’t explain everything. • The next series of slides spotlight the connection between ACEs and adult health. • Keep in mind as you look through the graphs, that this is just part of the story. There are many individuals with high ACE scores that do not have these poor health outcomes. • We will talk more about resiliency later.
    63. 63. Adverse Childhood Experiences vs. Smoking as an Adult 0 2 4 6 8 10 12 14 16 18 20 0 1 2 3 4-5 6 or more ACE Score
    64. 64. Adverse Childhood Experiences vs. Adult Alcoholism 0 2 4 6 8 10 12 14 16 18 %Alcoholic ACE Score 0 1 2 3 >=4
    65. 65. ACE Score vs. Intravenous Drug Use 0 0.5 1 1.5 2 2.5 3 3.5 %HaveInjectedDrugs 0 1 2 3 4 or more ACE Score
    66. 66. Adverse Childhood ExperiencesAdverse Childhood Experiences vs. Likelihood of > 50 Sexualvs. Likelihood of > 50 Sexual PartnersPartners 0 1 2 3 4 AdjustedOddsRatio 0 1 2 3 4 or more ACE Score
    67. 67. ACE Score vs. UnintendedACE Score vs. Unintended Pregnancy or Elective AbortionPregnancy or Elective Abortion 0 10 20 30 40 50 60 70 80 %haveUnintendedPG,orAB 0 1 2 3 4 or more ACE Score Unintended Pregnancy Elective Abortion
    68. 68. Childhood Experiences Underlie Chronic Depression 0 10 20 30 40 50 60 70 80 %WithaLifetimeHistoryof Depression 0 1 2 3 >=4 ACE Score Women Men
    69. 69. Childhood Experiences Underlie Later Suicide 0 5 10 15 20 25 %AttemptingSuicide ACE Score 0 1 2 3 >=4
    70. 70. ACE Score vs. Serious Job Problems 0 2 4 6 8 10 12 14 16 18 %withJobProblems 0 1 2 3 4 or more ACE Score
    71. 71. “A large portion of many health, safety and prosperity conditions is attributable to Adverse Childhood Experiences.” Washington Family Council
    72. 72. Health Care Costs • $2.6 trillion in US (2010) • Over 10 times amount spent in 1980 • 17.9% of the Gross Domestic Product • AZ – $13.8 billion in 2010 - 18% GDP • 75% of health spending is for chronic diseases (heart disease, cancer, stroke, and diabetes)
    73. 73. Reducing Costs Research shows that just asking about ACEs – significantly decreases doctor office visits and costs.
    74. 74. Pay Now or Pay Later • Pay now for programs proven to buffer the stress, or pay later in rising health costs. • “Early childhood investments of high quality have a lasting effect.” “$10 return on investment for every $1 spent.” (James Heckman, Noble
    75. 75. Prevention Works “It has been proven that effective early prevention efforts are less costly to our nation and to individuals than trying to fix the adverse effects of child maltreatment.” Bryan Samuels, Commissioner at U.S. Department of Health and Human Services.
    76. 76. Cost of Child Abuse • 2012 CDC Report - one year confirmed costs: $124 billion over lifetime of traumatized children
    77. 77. ACEsACEs are theare the Pipeline to PrisonPipeline to Prison • 1 in 6 state male inmates reported being physically or sexually abused before age 18, and many more witnessed interpersonal violence. • Over half of male inmates (56%) report experiencing childhood physical trauma. • Over one-quarter (1/4) of incarcerated men report being abandoned during childhood or adolescence • Of the more than 93,000 children currently incarcerated, between 75 and 93 percent have experienced at least one traumatic experience. Childhood and Adult Trauma Experiences of Incarcerated Persons and Their Relationship to Adult Behavioral Health Problems and Treatment) Int Journal of Environ Res Public Health. 2012 May; 9(5): 1908–1926. Published online 2012 May 18. Healing Invisible Wounds: Why Investing in ,
    78. 78. Our Challenge • We can and must “immunize” kids against the effects of ACEs. • We can and must reduce the numbers of ACEs for all children!
    79. 79. Caring Communities Can Help Reduce ACEs
    80. 80. Examples of Caring Communities Action • Health Care - Center for Youth Wellness, San Francisco • Education – Lincoln High, Walla Walla, WA • Medicine – Jefferson Co Public Health • Communities – Tarpon Springs, FL, Philadelphia Urban ACEs • Corrections - Alaska Family Violence • Faith Community - CA • Juvenile Justice
    81. 81. Examples of Caring Communities Action in AZ • Healthy Families Arizona • Family Support as part of In Home Services • Who Do You Trust with Your Child? • ACE Consortium • Safe Sleep • Regional Child Abuse Prevention Councils • Protective Factors Framework • Arizona’s Children Association’s Post Trauma Strengths Development Program • New Directions Institute • Maricopa Family Support Alliance • MyChild’sReady Home Visitation Alliance
    82. 82. How Do We Meet the Challenge?
    83. 83. Three Important Concepts • Protective Factors • Resilience • Trauma-Informed Care
    84. 84. Protective Factors • Increase health and well-being of children and families • Critical to success at home, work and community
    85. 85. Resilience • Ability to deal with life’s ups and downs • Resilience Trumps ACEs
    86. 86. Trauma Informed Care • Not “What’s wrong with you?”; instead “What happened to you?” • Symptoms (substance abuse, etc) are adaptations to trauma • Shift from “The denial stops here.” to “The recovery starts here.”
    87. 87. Lunch 
    88. 88. It Starts With You! • Identify and understand the importance of protective factors • Utilize protective factors in your own life • Empower others by educating and encouraging them to use protective factors
    89. 89. A Story of Resiliency “Where there’s breath there’s hope.” Tonier Cain For two decades Tonier “Neen” Cain endured routine physical and verbal abuse, homelessness, multiple rapes, beatings and was arrested 83 times. Her “upward spiral” began when she had the opportunity to go to a community trauma, mental health and addictions program. Healing Neen Trailer
    90. 90. Protective Factors • Conditions that increase health and well being • Critical for everyone regardless of age, sex, ethnicity or racial heritage, economic status, special needs, or the dynamics of the family unit • Buffers that provide support and coping strategies
    91. 91. Protective Factors that Strengthen Families and Communities • Nurturing and Attachment • Knowledge of Parenting and Child Development • Parental Resilience • Social Connections • Concrete Support in Time of Need • Social Emotional Competence of Children
    92. 92. Nurturing and Positive Relationships are the key to mentally healthy children and adolescents
    93. 93. Safe, Stable, Nurturing Relationships Safe = free from harm Stable = a high degree of consistency Nurturing = compassionate, responsive caregivers
    94. 94. Building Nurturing and Attachment • Observe, attend and listen to children • Provide safe and stable home life • Model caring behavior • Respond to child’s needs • Use positive discipline • Notice and reinforce child’s strengths
    95. 95. Nurturing and Attachment • Set up activities that promote bonding and attachment • Acknowledge nurturing behavior • Provide information on related topics: – early secure attachments – responding to cries – shaken baby syndrome – how father’s nurture, etc. • Be a caring adult or mentor a child
    96. 96. What Does This Look Like? Someone you turn to: • Who? • How you feel? • What she or he does?
    97. 97. Knowledge of Parenting and Child Development Why Is This Important? Parenting is not static If parents don’t understand behavior, they tend to interpret it as negative Normal challenges can lead to frustrations and harsh discipline
    98. 98. Knowledge of Parenting and Child Development Begin where parents are at: – discuss hopes and dreams for their children – identify strengths and build on them – set up a time or place where parents can discuss and get information – provide educational materials, websites
    99. 99. Parental Resilience Good outcomes in spite of serious threats, toxic stress Resilient people: – are prepared to be effective in the world – can adapt to challenges – are mentally healthy
    100. 100. Parental Resilience • Recognize early signs of stress and connect people to resources • Develop a trusting relationship and provide support • Be a good neighbor • Look for and point out inner strengths
    101. 101. The power of resilience moderates the effects of serious life challenges and provides hope and healing.
    102. 102. Begin with yourself • Take care of own mental health • Develop healthy coping devices (regular exercise, reading, listening to music, etc.) • Seek out healthy family and friends for support • Use community supports (counseling, substance abuse treatment, self-help programs, etc.)
    103. 103. Building Social Connections • Identify what parents have in place; build on it • Provide opportunities for parents to get together - use parents skills, abilities and interests • Look for community opportunities – faith based, schools, community centers, support groups • Provide encouragement and support to try new groups • Teach social skills
    104. 104. Concrete Supports in Time of Need • Food, shelter, basic services critical to child well-being • Link caregivers to community resources and extended family • Work on sustainability
    105. 105. Children’s Social and Emotional Competence • Build kid’s ability to express emotions, self-regulate behaviors and get along with others • Helps parents understand their children
    106. 106. Building Social/Emotional Competence • Teach social skills • Educate parents on importance of social/emotional skills • Provide healthy outlets – arts, sensory, exercise, etc. • Encourage parents to exchange ideas on what works • Take timely action when there is concern
    107. 107. Parent Café in a box…helps individuals or community agencies get started…(using) the five protective factors that help strengthen families.
    108. 108. Exercise Agreements •Speak from your own experience •Listen attentively •No judgments, positive or negative •Do not give advice •Confidentiality •Turn cell phone off
    109. 109. One-On-One Active Listening •One person answers the questions and the other is silent for 2.5 min, then switch… •Q1: Who are you? •Q2: Who is in your family?
    110. 110. One-On-One Debrief •How was that for you? •What did you learn about yourself?
    111. 111. One-On-One Conversation •Take 5 min or so to discuss the theme of Resilience… •From each card, one of you read aloud the question matching Resilience •Agree on one question and discuss
    112. 112. Conversation Harvest •Any “ah–ha” moments? •Write yourself a short commitment
    113. 113. Strategies to Build Strong Communities
    114. 114. Provide Information • Educational workshops • Radio announcements • Community meetings • Web-based • Written material • Conversations
    115. 115. Enhance Skills Offer workshops/activities designed to increase skills of participant: – Training – Classes – Consultation – Counseling – Team sports, scouting, 4H
    116. 116. Provide Support • Be a good neighbor • Offer mentoring or support groups • Offer to help • Spend quality and quantity time with a child; read a book, share a meal
    117. 117. Enhance Access and Reduce Barriers • Seek grants, build local collaborations • Offer food, shelter, seek professional help if needed • Link clients to effective faith based activities, recreation, parenting classes, domestic violence shelters/education
    118. 118. Change Consequences • Thank someone for their hard work • Publicly recognize a community group that helps strengthen families • Publish newspaper article highlighting someone in the community • Give rewards to individuals or businesses for helping in the community
    119. 119. Change the Physical Design • Lead/participate in clean-up effort • Initiate change to make your community safer • Set up place where parents can gather and get information • Volunteer to paint a home • Support your local Child Abuse Prevention Council
    120. 120. Modify/Change Policy • Talk to legislators and philanthropists about supporting effective programs • Contribute to child abuse prevention programs via a tax check off • Support positive parenting programs, and services for domestic violence and mental health education
    121. 121. Planning for Strong Communities and Raising Strong Kids • What is the goal you want to achieve in your community? • What strategy(ies) will you use? • Who will assist you? • Who will be your audience? • When will you implement your strategy? • How will you know if you are successful? • How will you sustain your efforts?
    122. 122. Planning for Strong Communities and Raising Strong Kids 2:00 – 2:30 Presentation Planning 2:30 – 3:00 Group Presentations
    123. 123. Now What? • Questions? • Ideas for utilizing ACE research in your community? • What resources do you need? • What challenges do you foresee?
    124. 124. Turn to Your Neighbor • Share what resonated the most with you today. • How are you going to use this information?
    125. 125. Question • How can we build protective factors in the families we serve? • How can we help build resiliency in the families we impact?
    126. 126. If our society is to prosper in the future, we need to make sure that all children have the opportunity to develop intellectually, socially and emotionally.
    127. 127. In Summary “It is easier to build strong children than to repair broken men” ~ Frederick Douglass (1817- 1895) • “Children make up 25% of our population, but 100% of our future.” ~Ian Jukes • Now what?
    128. 128. To Get Involved Contact Marcia Stanton, Child Abuse Prevention Coordinator, Phoenix Children’s Hospital Mark Klym, MPA, Child Abuse Prevention Coordinator Office of Prevention and Family Support, Division of Children, Youth, and Families
    129. 129. Parenting Resources • 1-877-705-KIDS (5437) - Birth to Five Parenting Questions Helpline • 1-800-4-A-CHILD (422-4453) - Crisis Line for emotional needs, info on child abuse/neglect Also go to: • • • •
    130. 130. Information & Resources • ACE Study findings and information - or • ACEs Too High – • National Scientific Council on the Developing Child at Harvard University - • SAHMSA – Early Childhood Trauma Resources
    131. 131. More Information & Resources • National Center for Trauma-Informed Care – • National Child Traumatic Stress Network – • Center for Study of Social Policy - strengthening families and protective factors – • Center for Injury Prevention and Control – • American Psychological Assn – Resilience Guide -
    132. 132. More Resources • 3 ½ hour ACE Online Course - $29 - • Ready Nation– • Resiliency Trumps ACEs – • Healing Neen - • NCAN Resource Booklet - nmonth/guide2012/ • ACE Response Network -
    133. 133. 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 ( Safe, Stable, Nurturing Relationships: The CDC National Center for Injury Prevention and Control, Violence Prevention has many resources on the prevention of child maltreatment ( and promoting nurturing relationships between children and caregivers ( ). 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 ( ). The Zero to Three Institute has many resources on the impact of trauma and building resiliency in young children ( ). First Things First has great info on the science of early brain development ( ).
    134. 134. Works Cited Economic Costs: CDC Injury Prevention Center includes well-researched articles on the cost of child abuse ( ). The Heckman Equation has compelling resources for upstream solutions to societal problems by investing in early and equal development of human potential ( Protective Factors: The Child Welfare Information Gateway has a wealth of well-researched resources for protecting children and strengthening families ( ). Environmental Prevention Strategies: The Community Anti-Drug Coalitions of America website includes resources for effective community problem-solving strategies ( ). The 7 Cs Creed: National Association for Children of Alcoholics has a downloadable kit for professionals on tips for working with children of alcoholics (
    135. 135. Helpful Clips to Enhance Your WorkshopAn overview of the ACE Study http:/youtube/v3A_HexLxDY/ A compelling video highlighting the importance of early experiences http://youtube/GbSp88PBe9E Early experiences shape brain development v=VNNsN9IJkws&feature=share&list=PLuKMerO1zya_3krFpcOKgaeB2_2z QgYua Caregiver responses shape brain development QSh6A&feature=share&list=PLuKMerO1zya_3krFpcOKgaeB2_2zQgYua Toxic Stress derails brain development v=rVwFkcOZHJw&feature=share&list=PLuKMerO1zya_3krFpcOKgaeB2_2z QgYua Lincoln High School and Health Center’s Trauma-sensitive approach http://youtube/Npd0B1pGx2U Resilience Trumps ACEs YouTube Channel Heeling Neen Trailer Change the First Five Years and You Change Everything”
    136. 136. Thank You for Helping Make Our Community Strong!