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ACEs: ADVERSE CHILDHOOD EXPERIENCES
Objectives of this Presentation
• Raise awareness and understanding about Adverse Childhood
Experiences research and application.
• Raise awareness and understanding of the CDC framework being
implemented to prevent Adverse Childhood Experiences: Essentials
for Childhood, Safe, Stable and Nurturing Relationships and
Environments.
• Inform about how Kansas and other states are moving forward with
this work using collective impact approach.
Introduction
• Childhood experiences of abuse, neglect &
family dysfunction
What are the
Adverse
Childhood
Experiences?
• These incidents harm social, cognitive &
emotional functioning of children;
• Dramatically upset the safe, nurturing
environments children need to thrive.
What is their
impact?
The ACE Study
One of the largest studies to assess associations
between childhood maltreatment health & well-
being later in life
Collaboration the Centers of Disease Control
& Kaiser Permanente’s Health Appraisal Clinic in
San Diego, CA
Initial phase 1995 - 1997
Adverse Childhood Experiences (ACE) Study
• Collective effort of Kaiser Permanente and Centers for Disease Control and
Prevention (CDC)
• The largest study of its kind to examine the health, social and economic effects
of ACEs over the lifespan (over 17,000 participants)
• Examined past history of abuse, family dysfunction and current health status
• Retrospective cohort study of an HMO population with average of 57 years
acestudy.org
ACEs Questionnaire
• Physical abuse
• Emotional abuse
• Sexual abuse
• An alcohol and/or drug abuser in the
household
• An incarcerated household member
• Someone who is chronically depressed,
mentally ill, institutionalized or
suicidal
• Mother is treated violently
• One or no parents
• Emotional or physical neglect
FROM ‘what’s wrong with you’
TO ‘what happened to you’
ACE STUDY PROVIDES A PARADIGM
SHIFT ON ADDICTIONS &
UNHEALTHY BEHAVIORS.
3 Types of ACEs
ACE Study Participants Experienced
17,000 ACE Study participants had the following:
26%
1 ACE
16%
2 ACEs
9.6%
3 ACEs 0 ACE
12.4%
4+ ACEs
36% experienced
64% have
at least 1 ACE
How Prevalent are ACEs?
The ACE Study revealed the following estimates:
The Impact of ACEs
ACE Score and Smoking Behaviors/
Smoking-Related Lung Disease
0
2
4
6
8
10
12
14
16
18
Early smoking
initiation
Current COPD
0
1
2
3
4 or more ACEs
#
with
health
problem
(%)
ACE Score and HIV Risks
0
2
4
6
8
10
12
14
16
18
Ever injected
drugs
Had 50 or more
intercourse
partners
Ever had an STD
0
1
2
3
4 or more ACEs
#
with
health
problem
(%)
ACE Score and Alcoholism,
Suicide Attempts or Sexual Assault
#
with
health
problem
(%)
0
5
10
15
20
25
30
35
Considers self an
alcoholic
Ever attempted
suicide
Sexually assaulted
as an adult (women)
0
1
2
3
4 or more ACEs
ACE Score and Teen Pregnancy/Paternity
#
with
health
problem
(%)
0
5
10
15
20
25
30
35
40
45
Intercourse by
age 15
Teen pregnancy Teen paternity
0
1
2
3
4 or more ACEs
ACE Score and Work Problems
Prevalence
(%)
0
5
10
15
20
25
Job problems Financial
problems
Absenteeism
0
1
2
3
4 or more ACEs
NATIONAL vs. KANSAS ACE DATA
Kansas BRFSS
• Random, digit dial telephone (landline and cell phone)
survey of non-institutionalized adults 18 years & older:
– health-related risk behaviors
– chronic health conditions
– use of preventive services
– conducted annually since 1992
• Sample size:
– 10,000+ in even years
– 20,000+ in odd years
• Core section & state added section
ACE Module for KS BRFSS
CDC developed a standardized ACE Module in 2008
KS BRFSS included ACE Module in 2014 and 2015 Survey
Module comprised of 11 questions
8 categories of ACEs are assessed by the module
Categories reflect childhood abuse or household dysfunction
ACE Study Participants
Kansas data compared to National study
% in Nation
41%
23%
13%
8%
15%
% in Kansas
45.2%
22.3%
11.5%
7.4%
13.5%
# of ACEs
0
1
2
3
4+
Prevalence of ACEs
Kansas data compared to National study
Prevalence of ACEs
Kansas data compared to National study, cont.
Summary of Kansas Results
women compared with men
those with lower annual household
income
those with lower educational attainment
non-Hispanic other and multiracial
adults
non-heterosexual adults
those less than 65 years old
ACEs are prevalent…1 in 2 KS adults experience at least one ACE.
HIGH ACE SCORES (3+) ARE SEEN AMONG:
Summary of Kansas Results, continued
When compared to adults with no ACEs, the adults with high
ACE scores (3+) have higher prevalence of:
Kansas data mirror findings in other states.
Public Health Implications
KS DATA HIGHLIGHT
need to increase awareness of ACEs as a public health issue.
ACE PREVENTION MAY HAVE
beneficial effects on long-term health of Kansans.
COLLABORATION BETWEEN STATEWIDE
PARTNERS WILL BE REQUIRED
to address this complex issue.
Child Maltreatment Prevention:
a public health issue
• Magnitude of the problem
• Significant Public Health
burden
• Potential contribution to
solutions
Washington School Classroom: ACEs
30 Students: high school sophomores & seniors
The Impact of ACEs, continued
As the number of ACEs increase, so do
the risk for negative health outcomes.
Healthy Development…DERAILED
Exposure to Violence During
Childhood Associated with
Telomere Erosion
• Telomeres are the ends of DNA strands,
which are shortened with each cellular
division and contribute to aging.
• Same children examined for telomere
erosion between 5 and 10 years of age.
• Physical abuse in childhood caused
advanced erosion of telomeres.
• Combination of physical abuse,
exposure to domestic violence or
bullying caused the most erosion.
• Children at increased risk for
decreased life span, earlier diseases.
Shalley I, Moffet TE, Sugden K, Williams B, Houts RM, Danese A, Mill J,
Arseneault I, Caspi A. Molecular Psychiatry 2012. Doi: 10.1038/mp/2012.3
Death
Birth
Adverse Childhood Experiences
Social, emotional &
cognitive impairments
Adoption of
health-risk behaviors
Disease,
injury & disability
Early
Death
Lifetime Influence of ACEs
How do ACEs Affect our Society?
What does Abuse Cost Us?
Non-fatal Child Maltreatment has an average lifetime
cost of $210,012 per victim (CDC 2012).
Compare to the lifetime costs of Type II Diabetes at $181,000.
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000
NOW WHAT???
Bridging Research & Practice
FIVE PROTECTIVE FACTORS
Resilience to Stress
Social Connections
Child Development Knowledge
Concrete Supports in Crisis
Parent/Child Attachment
Caregivers are
One Answer
3 Systems for Promoting Resilience
• Intellectual & employable
skills
• Self-regulation—self-
control, executive
function, flexible thinking
• Ability to direct & control
attention, emotion,
behavior
• Positive self-view,
efficacy
• Bonds with parents &/or
caregivers
• Positive relationships
with competent &
nurturing adults
• Friends or romantic
partners who provide a
sense of security &
belonging, help with
emotion coaching
• Faith, hope, sense of
meaning
• Engagement with
effective organizations—
schools, work, pro-social
groups
• Network of
supports/services &
opportunity to help
others
• Cultures providing
positive standards,
expectation, rituals,
relationships & supports
Capability
What helps individuals self-regulate?
– Massage
– Mindfulness, Reflection
– Pleasure
– Biofeedback
– Movement and Music
– Exercise and Play
– Physical Activities
– Practicing Connection
Attachment & Belonging
What helps to generate belonging?
– Developing ceremonies or rituals
– Including others in therapeutic and health
promoting activities
– Engaging in multiple family or whole
community dialogues
– Setting up mutual support or helping systems
– Creating art, movement, rhythm, music
– Learning together
Community Capacity
What builds community capacity for well-being?
– Opportunities for Everyone to Lead
– Rhythm & Ritual of Coming Together: focus on matters
of importance
– Reciprocity: learning, helping, generating
– Shared Identity: acting in concert for desired future
Synaptic Density
SOURCE: Harvard University Center on the Developing Child
BIRTH 6 YEARS 14 YEARS
700 new synapses (neural connections) every second
3 Core Concepts in
Early Development
• Experiences build brain
architecture/brain health.
• “Serve and Return”
interactions shapes brain
circuitry.
• Toxic stress derails healthy
development.
developingchild.harvard.edu
Essentials for
Childhood (EfC)
• EfC is the broad umbrella &
strategic direction for all child
maltreatment work through the
CDC.
• THEIR VISION: all children live
in safe, stable & nurturing
relationships and environments
to prevent child maltreatment &
to assure that children reach
their full potential.
• However, safe, stable &
nurturing relationships and
environments are important for
adults as well.
Essentials for
Childhood (EfC),continued
• SAFETY: the extent to which a child is
free from fear & secure from physical
or psychological harm within their
social & physical environment.
• STABILITY: the degree of
predictability & consistency in a
child’s social, emotional & physical
environment.
• NURTURING: the extent to which a
parent or caregiver is available & able
to sensitively respond to & meet the
needs of their child.
CDC’s strategic direction for CM prevention.
Moving from Isolated Impact…
Countless nonprofit, business & government organizations
each work to address social problems independently.
…to Collective Impact!
Fundamentally different, Collective Impact is a more disciplined, highly structured & higher
performing approach to large-scale social impact than other types of collaboration.
Essentials for Childhood
GOALS
1. Raise awareness & commitment to
support safe, stable & nurturing
relationships and environments &
prevent child maltreatment.
2. Use data to inform solutions.
3. Create the context for healthy
children and families through
norms change & programs.
4. Create the context for healthy
children & families through policies.
5 Elements of Collective Impact
• Common understanding of the problem
• Shared vision for change
Common Agenda
• Collecting data and measuring results
• Focus on performance management
• Shared accountability
Shared Measurement
• Differentiated approaches
• Willingness to adapt individual activities
• Coordination through joint plan of action
Mutually Reinforcing
Activities
• Consistent and open communication
• Focus on building trust
Continuous
Communication
• Separate organization(s) with staff
• Resources and skills to convene and coordinate
participating organizations
Backbone Support
Achieving Large-Scale Change through Collective Impact Involves
Five Key Elements
© 2014 FSG, fsg.org
Strategies that Address the Needs of Children & their Families
Level One Commitment States
2014-2018
• Coordinate and manage existing and new partnerships
with other child maltreatment prevention organizations
and non-traditional partners.
• Work with partners to identify strategies across sectors.
• Identify, coordinate, monitor and report on the strategies
implemented by multi-sector partners.
• Coordinate improvement processes (e.g. continuous
quality improvement for multi-sector partners to refine
strategies and document state-level impact of the efforts.
Kansas Collective Impact Team
• Business Alliance for Childhood Education
• Children’s Alliance of Kansas
• Children’s Mercy Hospital
• Courts
• Episcopal Diocese of Kansas
• Family Conservancy
• Health Care Foundation of Greater KC
• Innovative Leadership Strategies
• KU Center for Public Partnerships & Research
• KU Department of Social Welfare
• KU School of Medicine
• Kansas Action for Children
• Kansas Alliance of Children’s Trust Funds
• Kansas Attorney General’s Office
• Kansas Chapter of Academy of Pediatrics
• Kansas Chapter of Circle of Parents
• Kansas Chapter of Prevent Child Abuse America
• Kansas Child Advocacy Centers
• Kansas Children’s Cabinet and Trust Fund
• Kansas Children’s Service League
• Kansas City Coalition for Child Abuse Prevention
• Kansas Court Appointed Special Advocates
• Kansas Coalition Against Sexual & Domestic Violence
• Kansas Department on Aging & Disability Services
• Kansas Department for Children & Families
• Kansas Department of Corrections
• Kansas Department of Health &Environment
• Kansas Head Start Association
• Kansas Health Institute
• Kansas State Department of Education
• Kansas Statewide Parent Leadership Advisory Council
• Morris Family Foundation
• Prevent Child Abuse America
• Reaching Out From Within
• Washburn University School of Social Welfare
• Wesley Hospital
• Westar Energy
• Wichita Coalition for Child Abuse Prevention
• WSU Center for Community Support & Research
Resources to Learn More…
• cdc.gov/violenceprevention/
acestudy
• cdc.gov/violenceprevention/
childmaltreatment
• preventchildabuse.org
• kansaspowerofthepositive.org
THANK YOU!
Vicky Roper, Prevent Child Abuse Kansas Director
(316) 942.4261
vroper@kcsl.org

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  • 2. Objectives of this Presentation • Raise awareness and understanding about Adverse Childhood Experiences research and application. • Raise awareness and understanding of the CDC framework being implemented to prevent Adverse Childhood Experiences: Essentials for Childhood, Safe, Stable and Nurturing Relationships and Environments. • Inform about how Kansas and other states are moving forward with this work using collective impact approach.
  • 3. Introduction • Childhood experiences of abuse, neglect & family dysfunction What are the Adverse Childhood Experiences? • These incidents harm social, cognitive & emotional functioning of children; • Dramatically upset the safe, nurturing environments children need to thrive. What is their impact?
  • 4. The ACE Study One of the largest studies to assess associations between childhood maltreatment health & well- being later in life Collaboration the Centers of Disease Control & Kaiser Permanente’s Health Appraisal Clinic in San Diego, CA Initial phase 1995 - 1997
  • 5. Adverse Childhood Experiences (ACE) Study • Collective effort of Kaiser Permanente and Centers for Disease Control and Prevention (CDC) • The largest study of its kind to examine the health, social and economic effects of ACEs over the lifespan (over 17,000 participants) • Examined past history of abuse, family dysfunction and current health status • Retrospective cohort study of an HMO population with average of 57 years acestudy.org
  • 6. ACEs Questionnaire • Physical abuse • Emotional abuse • Sexual abuse • An alcohol and/or drug abuser in the household • An incarcerated household member • Someone who is chronically depressed, mentally ill, institutionalized or suicidal • Mother is treated violently • One or no parents • Emotional or physical neglect
  • 7. FROM ‘what’s wrong with you’ TO ‘what happened to you’ ACE STUDY PROVIDES A PARADIGM SHIFT ON ADDICTIONS & UNHEALTHY BEHAVIORS.
  • 8. 3 Types of ACEs
  • 9. ACE Study Participants Experienced 17,000 ACE Study participants had the following: 26% 1 ACE 16% 2 ACEs 9.6% 3 ACEs 0 ACE 12.4% 4+ ACEs 36% experienced 64% have at least 1 ACE
  • 10. How Prevalent are ACEs? The ACE Study revealed the following estimates:
  • 12. ACE Score and Smoking Behaviors/ Smoking-Related Lung Disease 0 2 4 6 8 10 12 14 16 18 Early smoking initiation Current COPD 0 1 2 3 4 or more ACEs # with health problem (%)
  • 13. ACE Score and HIV Risks 0 2 4 6 8 10 12 14 16 18 Ever injected drugs Had 50 or more intercourse partners Ever had an STD 0 1 2 3 4 or more ACEs # with health problem (%)
  • 14. ACE Score and Alcoholism, Suicide Attempts or Sexual Assault # with health problem (%) 0 5 10 15 20 25 30 35 Considers self an alcoholic Ever attempted suicide Sexually assaulted as an adult (women) 0 1 2 3 4 or more ACEs
  • 15. ACE Score and Teen Pregnancy/Paternity # with health problem (%) 0 5 10 15 20 25 30 35 40 45 Intercourse by age 15 Teen pregnancy Teen paternity 0 1 2 3 4 or more ACEs
  • 16. ACE Score and Work Problems Prevalence (%) 0 5 10 15 20 25 Job problems Financial problems Absenteeism 0 1 2 3 4 or more ACEs
  • 18. Kansas BRFSS • Random, digit dial telephone (landline and cell phone) survey of non-institutionalized adults 18 years & older: – health-related risk behaviors – chronic health conditions – use of preventive services – conducted annually since 1992 • Sample size: – 10,000+ in even years – 20,000+ in odd years • Core section & state added section
  • 19. ACE Module for KS BRFSS CDC developed a standardized ACE Module in 2008 KS BRFSS included ACE Module in 2014 and 2015 Survey Module comprised of 11 questions 8 categories of ACEs are assessed by the module Categories reflect childhood abuse or household dysfunction
  • 20. ACE Study Participants Kansas data compared to National study % in Nation 41% 23% 13% 8% 15% % in Kansas 45.2% 22.3% 11.5% 7.4% 13.5% # of ACEs 0 1 2 3 4+
  • 21. Prevalence of ACEs Kansas data compared to National study
  • 22. Prevalence of ACEs Kansas data compared to National study, cont.
  • 23. Summary of Kansas Results women compared with men those with lower annual household income those with lower educational attainment non-Hispanic other and multiracial adults non-heterosexual adults those less than 65 years old ACEs are prevalent…1 in 2 KS adults experience at least one ACE. HIGH ACE SCORES (3+) ARE SEEN AMONG:
  • 24. Summary of Kansas Results, continued When compared to adults with no ACEs, the adults with high ACE scores (3+) have higher prevalence of: Kansas data mirror findings in other states.
  • 25. Public Health Implications KS DATA HIGHLIGHT need to increase awareness of ACEs as a public health issue. ACE PREVENTION MAY HAVE beneficial effects on long-term health of Kansans. COLLABORATION BETWEEN STATEWIDE PARTNERS WILL BE REQUIRED to address this complex issue.
  • 26. Child Maltreatment Prevention: a public health issue • Magnitude of the problem • Significant Public Health burden • Potential contribution to solutions
  • 27. Washington School Classroom: ACEs 30 Students: high school sophomores & seniors
  • 28. The Impact of ACEs, continued As the number of ACEs increase, so do the risk for negative health outcomes.
  • 30. Exposure to Violence During Childhood Associated with Telomere Erosion • Telomeres are the ends of DNA strands, which are shortened with each cellular division and contribute to aging. • Same children examined for telomere erosion between 5 and 10 years of age. • Physical abuse in childhood caused advanced erosion of telomeres. • Combination of physical abuse, exposure to domestic violence or bullying caused the most erosion. • Children at increased risk for decreased life span, earlier diseases. Shalley I, Moffet TE, Sugden K, Williams B, Houts RM, Danese A, Mill J, Arseneault I, Caspi A. Molecular Psychiatry 2012. Doi: 10.1038/mp/2012.3
  • 31. Death Birth Adverse Childhood Experiences Social, emotional & cognitive impairments Adoption of health-risk behaviors Disease, injury & disability Early Death Lifetime Influence of ACEs
  • 32. How do ACEs Affect our Society?
  • 33. What does Abuse Cost Us? Non-fatal Child Maltreatment has an average lifetime cost of $210,012 per victim (CDC 2012). Compare to the lifetime costs of Type II Diabetes at $181,000. $0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 $160,000
  • 36. FIVE PROTECTIVE FACTORS Resilience to Stress Social Connections Child Development Knowledge Concrete Supports in Crisis Parent/Child Attachment Caregivers are One Answer
  • 37. 3 Systems for Promoting Resilience • Intellectual & employable skills • Self-regulation—self- control, executive function, flexible thinking • Ability to direct & control attention, emotion, behavior • Positive self-view, efficacy • Bonds with parents &/or caregivers • Positive relationships with competent & nurturing adults • Friends or romantic partners who provide a sense of security & belonging, help with emotion coaching • Faith, hope, sense of meaning • Engagement with effective organizations— schools, work, pro-social groups • Network of supports/services & opportunity to help others • Cultures providing positive standards, expectation, rituals, relationships & supports
  • 38. Capability What helps individuals self-regulate? – Massage – Mindfulness, Reflection – Pleasure – Biofeedback – Movement and Music – Exercise and Play – Physical Activities – Practicing Connection
  • 39. Attachment & Belonging What helps to generate belonging? – Developing ceremonies or rituals – Including others in therapeutic and health promoting activities – Engaging in multiple family or whole community dialogues – Setting up mutual support or helping systems – Creating art, movement, rhythm, music – Learning together
  • 40. Community Capacity What builds community capacity for well-being? – Opportunities for Everyone to Lead – Rhythm & Ritual of Coming Together: focus on matters of importance – Reciprocity: learning, helping, generating – Shared Identity: acting in concert for desired future
  • 41. Synaptic Density SOURCE: Harvard University Center on the Developing Child BIRTH 6 YEARS 14 YEARS 700 new synapses (neural connections) every second
  • 42. 3 Core Concepts in Early Development • Experiences build brain architecture/brain health. • “Serve and Return” interactions shapes brain circuitry. • Toxic stress derails healthy development. developingchild.harvard.edu
  • 43. Essentials for Childhood (EfC) • EfC is the broad umbrella & strategic direction for all child maltreatment work through the CDC. • THEIR VISION: all children live in safe, stable & nurturing relationships and environments to prevent child maltreatment & to assure that children reach their full potential. • However, safe, stable & nurturing relationships and environments are important for adults as well.
  • 44. Essentials for Childhood (EfC),continued • SAFETY: the extent to which a child is free from fear & secure from physical or psychological harm within their social & physical environment. • STABILITY: the degree of predictability & consistency in a child’s social, emotional & physical environment. • NURTURING: the extent to which a parent or caregiver is available & able to sensitively respond to & meet the needs of their child. CDC’s strategic direction for CM prevention.
  • 45. Moving from Isolated Impact… Countless nonprofit, business & government organizations each work to address social problems independently.
  • 46. …to Collective Impact! Fundamentally different, Collective Impact is a more disciplined, highly structured & higher performing approach to large-scale social impact than other types of collaboration.
  • 47. Essentials for Childhood GOALS 1. Raise awareness & commitment to support safe, stable & nurturing relationships and environments & prevent child maltreatment. 2. Use data to inform solutions. 3. Create the context for healthy children and families through norms change & programs. 4. Create the context for healthy children & families through policies.
  • 48. 5 Elements of Collective Impact • Common understanding of the problem • Shared vision for change Common Agenda • Collecting data and measuring results • Focus on performance management • Shared accountability Shared Measurement • Differentiated approaches • Willingness to adapt individual activities • Coordination through joint plan of action Mutually Reinforcing Activities • Consistent and open communication • Focus on building trust Continuous Communication • Separate organization(s) with staff • Resources and skills to convene and coordinate participating organizations Backbone Support Achieving Large-Scale Change through Collective Impact Involves Five Key Elements © 2014 FSG, fsg.org
  • 49. Strategies that Address the Needs of Children & their Families
  • 50. Level One Commitment States 2014-2018 • Coordinate and manage existing and new partnerships with other child maltreatment prevention organizations and non-traditional partners. • Work with partners to identify strategies across sectors. • Identify, coordinate, monitor and report on the strategies implemented by multi-sector partners. • Coordinate improvement processes (e.g. continuous quality improvement for multi-sector partners to refine strategies and document state-level impact of the efforts.
  • 51.
  • 52. Kansas Collective Impact Team • Business Alliance for Childhood Education • Children’s Alliance of Kansas • Children’s Mercy Hospital • Courts • Episcopal Diocese of Kansas • Family Conservancy • Health Care Foundation of Greater KC • Innovative Leadership Strategies • KU Center for Public Partnerships & Research • KU Department of Social Welfare • KU School of Medicine • Kansas Action for Children • Kansas Alliance of Children’s Trust Funds • Kansas Attorney General’s Office • Kansas Chapter of Academy of Pediatrics • Kansas Chapter of Circle of Parents • Kansas Chapter of Prevent Child Abuse America • Kansas Child Advocacy Centers • Kansas Children’s Cabinet and Trust Fund • Kansas Children’s Service League • Kansas City Coalition for Child Abuse Prevention • Kansas Court Appointed Special Advocates • Kansas Coalition Against Sexual & Domestic Violence • Kansas Department on Aging & Disability Services • Kansas Department for Children & Families • Kansas Department of Corrections • Kansas Department of Health &Environment • Kansas Head Start Association • Kansas Health Institute • Kansas State Department of Education • Kansas Statewide Parent Leadership Advisory Council • Morris Family Foundation • Prevent Child Abuse America • Reaching Out From Within • Washburn University School of Social Welfare • Wesley Hospital • Westar Energy • Wichita Coalition for Child Abuse Prevention • WSU Center for Community Support & Research
  • 53. Resources to Learn More… • cdc.gov/violenceprevention/ acestudy • cdc.gov/violenceprevention/ childmaltreatment • preventchildabuse.org • kansaspowerofthepositive.org
  • 54. THANK YOU! Vicky Roper, Prevent Child Abuse Kansas Director (316) 942.4261 vroper@kcsl.org