Responding to ACES in Monroe
Joe Neigel January 8, 2015
Our Goals This Morning Review the Adverse Childhood Experiences Study and how early life trauma influences behavior, health outcomes and readiness to learn. Discover how ACES impact students and educators at Park Place Middle School.
Consider simple, evidence-based strategies we can adopt to mitigate the harm ACES cause to youth, the learning environment and community.
Adverse Childhood Experiences Study (ACES) ACES began as a weight-loss study at Kaiser-Permanente in Southern California. It became the largest study ever completed to examine the health and social effects of traumatic childhood experiences over the lifespan.
Middle class, average age of 57 80% white, 10% black, 10% Asian 74% some college 44% graduated college 49.5% men
Examines three general forms of abuse and household dysfunction.
The Adverse Experiences • Child physical abuse • Child sexual abuse • Child emotional abuse
• Neglect • Mentally ill, depressed or suicidal person in the home • Drug addicted or alcoholic family member • Witnessing domestic violence against the mother • Loss of a parent to death or abandonment, including abandonment by divorce • Incarceration of any family member
ACE Score Calculator
ACEs in Snohomish County 40.00%
35.30%
Snohomish Washington
30.00%
22.90% 20.00%
20.10% 12.60%
10.00%
9.20%
0.00% 0
1
2
3
4 or More
ACE Study Findings ACEs are very common. They are well-concealed. The ACE Study found that the number of categories, not necessarily the frequency or severity of the experiences within a category, determine health outcomes across the population as a whole. ACEs are strong indicators of what happens later in life, in terms of health risks, diseases and premature death.
The Science Behind ACES A child’s environment and experience shapes their behavior and health. Our brain is designed to prioritize survival. Cortisol is released when our “Fight, Flight, or Freeze” response is triggered.
Toxic Stress
Toxic Stress Prolonged exposure to Cortisol is toxic, and makes permanent changes to the brain. This means our at-risk kids may be perfectly suited to survive in their home environment, but they may not know how to act in the classroom, community or other “normal” situations.
Recognizing some signs of traumatic brain development Hypervigilance - “Always on the ready.” Display of trauma induced ADHD symptoms, including an inability to stay on task or follow directions. Early onset of sexualized behaviors and activity. More impulsive, aggressive and disruptive behaviors, including those leading to suspension. Being less able to tolerate stress.
Other Negative Effects
Prolonged exposure to Cortisol is shown to have negative effects, such as:
Impaired cognitive performance
Weakened immune system
Hyperglycemia (fatigue, excessive thirst/urination)
Decreased bone density
Decrease in muscle tissue
Higher blood pressure
Slower healing, and other health consequences
Increased risk of physical and mental health problems, including development of health risk behaviors
Graded Relationships in Health Risk Behaviors • There is a strong “dose/response” relationship between a person’s ACE score and the likelihood they will adopt personal solutions that lead to serious health problems. • Dose/Response is a direct measure of “cause and effect.”
Dose-Response: More Gas = More Miles Number of Miles You Can Drive (Response)
350 300 250 200 150 100 50 0 1
2
3
4
5
6 7 8 9 Gallons of Gas (Dose Gets Bigger)
10 11 12 13 14 15
Smoking • We can see the cause and effect relationship ACEs create in people and in populations.
Alcoholism • We can see the cause and effect relationship ACEs create in people and in populations.
Intravenous Drug Use • We can see the cause and effect relationship ACEs create in people and in populations.
Chronic Depression
% With a Lifetime History of Depression
• We can see the cause and effect relationship ACEs create in people and in populations. Women Men
80 70 60 50 40 30 20 10 0 0
1
2 ACE Score
3
>=4
Attempted Suicide • We can see the cause and effect relationship ACEs create in people and in populations.
ACEs lead to risk factors for the 10 most common causes of early death in the United States
Reframing Our Point of View •
With an ACE score of 0, the majority of adults have few, if any, risk factors for diseases leading to early death
•
With an ACE score of 4 or more, the majority of adults have multiple risk factors for these diseases, or the diseases themselves.
•
Prepare yourself for this –
Much of what we see as problem behaviors should actually be viewed as a personal solution to an unrecognized prior adversity.
ACEs Impact Park Place MS We also know ACES drive : • Special education needs • Grade repetition
• Problems at school • Educator burnout
Meet Mallory
Getting to Know Mallory • Mallory is in 8th grade at Park Place Middle School. • Mallory’s Counselor, Jennifer Garcia, knows her mother physically abused her in the past. As a result, her known ACE Score is “1.”
• Keep in mind - ACEs travel in clusters: Among people exposed to physical abuse, 84% report at least 2 additional ACEs.
Mallory’s Grades Mallory appears to have trouble paying attention in class. She doesn’t turn in her homework and seems to have a hard time following directions; her grades reflect this. • 8th graders like Mallory, who indicated being victims of physical abuse on our Healthy Youth Survey, were nearly twice as likely (1.7x) to report getting C’s, D’s and F’s.
Bullying and Safety at School Mallory has trouble making lasting friendships and is frequently the target of bullying behavior. • 8th graders like Mallory, who indicated they had been physically abused by an adult, were: Nearly twice as likely (1.8x) to report being the victims of bullying. 2.5x more likely to report missing days of school because they felt unsafe.
Mallory’s Mental Health Mallory seems pretty disengaged in class and always looks tired. She can’t seem to remember facts from 10 minutes ago. • 8th graders who report being physically abused by an adult were 2.5x more likely to report being depressed on the last HYS. • Students like Mallory were also 2.9x more likely to report contemplating suicide. • Unfortunately, these 8th graders are also 2.5x less likely to report knowing an adult they can turn to when feeling depressed.
Mallory’s Personal Solutions Mallory was caught bringing a flask of alcohol to school in 7th grade. She talked with Sandra Olson and avoided most of her suspension, but she and her family really haven’t engaged with any helping adults since then. • 8th graders like Mallory are 3.8x more likely to report current alcohol use, and • They are 3.1x more likely indicate any other type of current drug use, including Marijuana.
Mallory’s in every classroom
Nearly 1 in 7 8th graders at Park Place Middle School indicated they had been physically abused by an adult on the last Healthy Youth Survey.
ACE Effects in School Low School Engagement 60% 50% 40% 30% 20% 10% 0% 0 ACE
1 ACE
2 ACE
3+ ACEs
Source: National Survey of Children’s Health, Johns Hopkins University (2012)
ACE Effects in School Does Not Finish Tasks Started 60% 50% 40% 30% 20% 10% 0% 0 ACE
1 ACE
2 ACE
3+ ACEs
Source: National Survey of Children’s Health, Johns Hopkins University (2012)
ACE Effects in School Highly Externalizing Behavior 40% 35% 30% 25% 20%
15% 10% 5% 0% 0 ACE
1 ACE
2 ACE
3+ ACEs
Source: National Survey of Children’s Health, Johns Hopkins University (2012)
ACE Effects in School Household Contacted Due to Problems at School 60% 50% 40% 30% 20% 10% 0% 0 ACE
1 ACE
2 ACE
3+ ACEs
Source: National Survey of Children’s Health, Johns Hopkins University (2012)
ACE Effects in School Grade Repetition 25% 20% 15% 10% 5% 0% 0 ACE
1 ACE
2 ACE
3+ ACEs
Source: National Survey of Children’s Health, Johns Hopkins University (2012)
Beyond the Hallways Life-long Negative Outcomes Linked to ACEs Partial List of ACE Dose/Response Outcomes Alcoholism & alcohol abuse
School Drop-Out
Chronic obstructive pulmonary disease & ischemic heart disease
Intimate partner violence— perpetration & victimization
Depression and other MH issues
Sexually transmitted disease
Chronic Unemployment
Obesity
High risk sexual activity
Suicide attempts
Illicit drug use
Unintended pregnancy
Intimate partner violence
Early Death
Three or more marriages
Increased Emergency Room Use
Increased Pharmacy Use
Significant Financial Problems
What Are the Implications? To put it simply, childhood experiences are the most powerful determinants of who we become as adults.
Population Attributable Risk PAR = The difference in rate of a condition between an exposed population and an unexposed population.
In this case, it is a calculation used by the CDC to estimate the proportion of a health outcome that is attributable to ACE Takes into account: The increased risk due to each level of ACE The prevalence of the number of ACE categories
Population Attributable Risk Current Smoking Smoking Not Attributable to Ace
21.7% 78.3%
Risk data from Felitti, et. Al: PAR analysis: RE Voorhees
Smoking Attributable to ACE
Population Attributable Risk Ever Using Illicit Drugs
32.1% 67.9%
Risk data from Felitti, et. Al: PAR analysis: RE Voorhees
32.1% not attributable to ACE 67.9% attributable to ACE
Population Attributable Risk Alcoholism
3.2%
96.8%
Risk data from Felitti, et. Al: PAR analysis: RE Voorhees
3.2% of selfreported alcoholism not attributable to ACE 96.8% of selfreported alcoholism attributable to ACE
Population Attributable Risk Reporting Having Attempted Suicide
100%
Risk data from Felitti, et. Al: PAR analysis: RE Voorhees
0% of attempted suicide not attributable to ACE 100% of attempted suicide is attributable to ACE
How ACES Increase Suicide Attempts 1 of 100 people with 0 ACEs attempt suicide
10 of 100 people with 3 ACEs attempt suicide
20 of 100 people with 7 ACEs attempt suicide
ACEs Path “Personal Solution”
ACEs Impact Mortality
Percent in Age Group
60 50 40
19-34
35-49
50-64
>=65
30 20 10 0 0
2 ACE Score
4
Psychological Depletion • Whether you like it or not, many of you are on the ACEs frontline. • The constant demand of caring for others as you manage your classrooms, clients and even your families can lead to burnout: • Illness • Chronic fatigue • Emotional exhaustion • Indifference or detachment • Isolation • A lack of personal satisfaction
• Trauma-informed homes, schools and communities can create an environment where adults and students with injured brains will thrive. • Evidence-based Kernels can lead us from intuitive responses to intentional action.
• Safe and predictable environments are the keys to working successfully with trauma-impacted youth.
ARC - Managing Affect • Mood is your internal emotional state. • Affect is how you externalize your emotions through verbal and non-verbal cues. • Research shows that trauma-impacted youth and adults are particularly aware of changes in affect, which trigger the fight, flight, or freeze response and decreases the capacity to learn.
Attachment, Self-Regulation & Competency Kinniburgh, Blaustein, Spinazzola & van der Kolk, 2005, Psychiatric Annals, pp. 424-430.
ARC - Attunement • Traumatized children often have difficulty communicating, so their behaviors may then become a “front” for conveying unmet needs or their own unregulated affect. • Adults may respond to the most distressing symptom, rather than the underlying emotion or need. • We need to develop a community that’s trained to ask “What’s happening here?” rather than “What’s wrong with this child?” Attachment, Self-Regulation & Competency Kinniburgh, Blaustein, Spinazzola & van der Kolk, 2005, Psychiatric Annals, pp. 424-430.
ARC - Consistency • Being predictable and having consistent responses to behavior are vital to establishing safety and reducing a child’s need to exert control. • Traumatized children may initially react to negative or positive responses.
• An intentional focus on building success, rather than establishing limits – which may be associated with powerlessness or vulnerability – should be our priority. Attachment, Self-Regulation & Competency Kinniburgh, Blaustein, Spinazzola & van der Kolk, 2005, Psychiatric Annals, pp. 424-430.
ARC - Routines & Rituals • Building routines and rituals, particularly around trouble areas, can make our classrooms, offices and homes fun and predictable.
• Research shows that establishing routines enhances student: Feelings of safety Ability to build trust and feeling of reliability within a relationship Anticipation of the event Attachment, Self-Regulation & Competency Kinniburgh, Blaustein, Spinazzola & van der Kolk, 2005, Psychiatric Annals, pp. 424-430.
ARC & Compassionate Schools • These four strategies come from the Attachment, SelfRegulation and Competency research conducted by Kinniburgh and Blaustein. • You can learn more about ARC framework and training at www.traumacenter.org • The Compassionate Schools Initiative from OSPI also provides a framework for understanding the negative impacts of stress and trauma on learning.
• Kernels are low or no-cost to implement. • That means we can unleash access to strategies that support safety, relationship and skill building essential to the foundations of successful brain development. • Kernels give us a way to implement evidence based practices that will mitigate the ACES trajectory.
What are Kernels?! • A kernel is the smallest unit of scientifically proven behavioral influence. • Kernels produce quick easily measured change that can grow into much bigger change over time.
• They can be used alone OR combined with other kernels to create new programs, strategies or policies. • Combinations of Kernels are considered “behavioral vaccines.” • “Planted” Kernels create a culture.
Omega-3 Supplementation • Omega 3 has no harmful effects • Well-documented evidence for Reducing aggression, violence, depression, bipolar disorder, post partum depression and borderline personality disorder • 2002 Oxford University study found 37% reduction in inmate aggression; 2009 Dutch National Agency of Correctional Institutions Study found 34% reduction in inmate aggression compared to control groups. • In 2006, the American Psychiatric Association recommend that all psychiatric patients receive at least 1 gram of omega-3 per day to reduce symptoms of mental illness.
Omega-3 Supplementation
• The alterations in brain chemistry that have resulted from our changing diet during the last 50 years contributes to trends of depression, bipolar disorder, autism, violence and academic problems.
Play • Physical Play between fathers and their children increases a child’s ability to have healthy relationships. Mothers can do this type of play, too; it teaches basic skills for making and playing with friends. • Non-Directive Play – when the parent sits beside the child and describes out-loud what the child is doing – improves the relationship with the parent, increases the happiness and contentment of the child, and results in greater attention span, improved creativity and resourcefulness. • Parent/child play is associated with lower rates of delinquency, substance abuse problems and psychiatric disorders such as depression and anxiety problems.
Turtle Breathing • “Turtle Breathing” is a technique for helping children with controlling anger. • Some parents use this technique in conjunction with the scripted story, “Tucker Turtle Takes Time to Tuck and Think.” This technique:
• Reduces anxiety • Reduces temper tantrums
• Increases resiliency • Increases self-control
Turtle Breathing • Model remaining calm • Teach the child the steps of how to control feelings and calm down • Step 1: Recognize your feeling(s) • Step 2: Think “stop” • Step 3: Go inside your “shell” and take 3 deep breaths • Step 4: Come out when calm and think of a “solution” • Practice steps frequently • Recognize and comment when the child stays calm • Involve other families: teach the “Turtle Technique” • Helps children Prepare for and handle possible disappointment or change
Challenge – Feelings of Safety
Pleasant Greeting with Physical Touch • Also known as “handshakes.” • Frequent friendly physical and verbal greetings impact social status and perceptions of safety and harm. • It also affects behavior streams of aggression, hostility or politeness.
Challenge – Praise
Verbal Praise When any person receives specific, spoken recognition for engagement in a target act or behavior, it is widely demonstrated to: • Improve school performance • Improve adult/child interactions • Improve organizational functioning • Increase the frequency of the target behavior
Verbal Praise As a Social Reinforcer What are the social reinforcers in your home, classroom or community for this behavior?
Paying attention.
Verbal Praise As a Social Reinforcer How about for this behavior?
Showing off.
Peer to Peer Notes Notes of praise written from one peer to another, then read aloud or posted on a public display is widely shown to: • Increase positive friendships • Reduce neighborhood disorganization and crime • Increase sense of safety • Increase volunteerism • Increase behaviors you want to see more of
Adult to Child Notes • Notes from adults to children recognizing them for a SPECIFIC action or behavior is demonstrated to help youth of all ages to: • Do better at school • Be more socially competent
• Reduce ADHD, aggression and problem behaviors • Increase the behaviors you want to see more of
Copy Cat (Paragraph Shrinking) • After talking with your child, ask him to repeat what was said in 8-10 words. • Repeat if summary is poor. • Praise if the summary is good. • Helps with retention and understanding of what is said or read.
The Social Development Strategy
Random Calling This kernel is sometimes referred to as “Ritalin on a Stick” and is proven effective by research. Start by putting the names of all the students in the classroom on separate sticks. Every few minutes, the teacher picks a stick randomly to call on student to answer a question, to help, or to do something that maintains attention, generates motor behavior and creates a response. Typically, the stick is put back into the container so that might drawn again, randomly at any given time. Random calling results in:
Equality in participation. Increased attention will be paid to the lesson Increased academic performance Decreases in disruptive behavior
Challenge – Recognition
Positive Note Home for Inhibition When an adult sends a positive note home with a student for inhibiting an otherwise disruptive behavior, good things happen, particularly when a reward at home occurs in response. This strategy is demonstrated to reduce disruptive and aggressive behavior, problems at home and increases engagement at school.
Principal Lottery When a status figure sends a note home or calls a parent about a student’s positive behavior, research shows that action results in:
Increases in academic achievement Reductions in disruptive behavior
Reductions in aggression
Auditory/Visual Signal for Transition The attention kernel works for students and adults. It results in: Immediate reduction in transition time
Increased academic engagement Reduced disruptive behavior Reduced aggression and bullying Reduced trauma response in traumatized people.
Beat the Timer Beat the timer makes daily routines run smoother, reduces parent/child conflict and reduces accidental attention to negative behavior. Research shows that this simple game: • Increases compliance • Increases accuracy and completion of homework
• Helps with chores
Beat the Timer Steps: • Announce Beat the Timer • Say how long the timer will be set for • Say what behaviors are to beat the timer • Announce the timer is about to begin • Praise positive behavior while timer is ticking • Celebrate success and occasionally reward
Premack’s Principle Also known as the Mystery Motivator, Granny’s Wacky Prizes, Prize Bowl and the Game of Life. Results in a reduction in deviant behavior across the lifespan, reduces problem behavior at school, increases desirable behavior in all age groups and reduces addiction. Motivates youth and adults to do their best and improve Taps into “intrinsic” motivations Fosters self-regulation instead of excitement
Brain on the Ball • Suitable for preschoolers through adults • Sitting on therapy balls is shown to increase attention, improve academic achievement, reduces ADHD symptoms without medication and reduce disruptive behavior
Other Kernels Graphic/Node Maps Choral Responding Peer to Peer Tutoring Nasal Breathing Private Reprimands So Much More!
Advocating for Policy Change • Many agencies and initiatives want to understand how to improve outcomes for youth and adults, but don’t know about, or what to do about, ACES. • We may need a paradigm shift before we can affect community wide change. Are we treating the smoke, or the fire? • Besides for raising awareness, the number one way you can advocate for change is by advocating for ACES screening. Screening is important for two reasons: • Showing how ACES impact children can create the conditions needed for committed and urgent participation by child serving systems. • Establishing the prevalence and impact of ACES through local data can drive service and resource allocation decisions.
The Bottom Line • Understanding ACES gives you the power to significantly impact the trauma trajectory of youth in your care, whether you’re a parent or a professional… • Remember Kaiser Permanente’s diet and nutrition program dropouts? The researchers learned that their very successful intervention wasn’t just treating nutrition problems, it was treating personal solutions! • Take away a person’s solution before they discover a better one, and you’re just digging a hole for them to fall back into. • Partner with me. If you need it, I give you my permission to do what’s in your heart.
Johnny
Resources Presenter:
Joe Neigel Snohomish County Human Services Alcohol and Other Drug Prevention 3000 Rockefeller Ave. m/s 305 Everett, WA 98201 (425) 388-7227 joseph.neigel@snoco.org
Power Point:
http://bit.ly/ACESinMONROEwa
Kernels:
http://promiseneighborhoods.org/kernels/ Or http://bit.ly/embry_kernels
ACES:
http://www.cdc.gov/ace/index.htm Or http://www.acestudy.org/ Or http://www.fpc.wa.gov/ Or http://www.acestoohigh.com
ARC Training:
http://www.traumacenter.org/research/ascot.php
OSPI Initiative:
http://www.k12.wa.us/CompassionateSchools/
Coalition Strategy • Consider this: • Dr. Vincent Fellitti, a co-principal investigator of the ACES study, believes that parenting classes are THE vital response to preventing the intergenerational transmission of ACES. • In fact, students who report coming from families with poor family management skills are nearly 2.5x more likely to be suspended from school and 5.6x more likely to be arrested by 10th grade.
Spotlight: Parenting Wisely •
Parenting Wisely is evidence-based and proven effective. Extensive research and clinical tests show that use of Parenting Wisely results in: • • • • •
•
Increased knowledge and use of good parenting skills A decrease in youth behavior problems Improved problem solving Reduced spousal violence and violence toward their children Increased engagement in parenting classes
Success of the program has earned it the ranking as a SAMHSA “Model Program” and an OJJDP “Exemplary Program” as well as many other honors and rankings.
The Darrington Experience • After seeing a presentation like this, a champion emerged at Darrington Elementary School. With her help, we identified the Good Behavior Game and Brain on the Ball as strategies that were a good fit for her classroom. • Research shows the Good Behavior Game implemented in a 1st grade classroom for one school year produces: • 60-90 minutes more time to teach and learn each day. • 75-125 fewer disruptions per hour in classes. • 20%-30% reduction in need for special education
The Darrington Experience • The effects are even more profound over the lifetime of a Good Behavior Game participant: • 50% - 70% reduction in mental health difficulties (e.g., ADHD and conduct symptoms). • A 10% to 30% reduction injuries or stress related complaints. • Reduction in directly observable symptoms of ADHD such as inattention and fidgeting, even for children not on medication. • 30% to 60% reduction in referrals, suspensions or expulsions • At age 13, reduced initiation of smoking by 26% and of hard drugs by more than 50%. • At age 19, increased the likelihood of high school graduation by 21% and of college attendance by 62%.
Our Investment • The County invested approximately $450 in Good Behavior Game manuals and materials. • Teachers noticed immediate reductions in disruptions and increases in teaching time. • Teachers implemented the Good Behavior Game in combination with another kernel – alternative seating strategy. • They replaced all chairs in 1st – 3rd grade with therapy balls.
Our Investment • Therapy balls were ordered to each student’s measurement, and had feet to prevent rolling or tip-overs.
Our Investment • Teachers report: • The kids like them • Helps them focus • Works especially well partnered with the “Behavior Game” • Comfortable • Better handwriting • Seems to give the students stamina for writing for longer periods of time • In other classrooms, extra balls are used as a reward. • Rate of disruptions per student per hour: Goheen (74% reduction) and Monte Calvo (86% reduction) teaching Math.