Thanks to everyone who came to CCTC’s panel discussion on mobilizing a public health response to toxic stress and for joining ACEs connection to continue the discussion. Now we want to hear from you: how does Philadelphia go about creating a public health response to this public health issue? How can we make our systems, organizations, and communities more trauma-informed and responsive?
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What a great point, Roxy. I wonder if this is a grassroots effort, or an institutional effort that would be needed to make that happen.
We must have multi-generational solutions that acknowledge and address parents'/caregivers trauma histories and ACEs. Just as we know that it is difficult for children to learn when they are experiencing symptoms related to trauma the same can be true for adults. I'm involved in two programs serving young children and caregivers to break the cycle of intergenerational trauma transmission by focusing on and treating parents' trauma and its affects on their parenting. In one, we are using the SELF model, a component of the Sanctuary Model with caregivers in an Early Head Start Program. In another, we are using Child Parent Psychotherapy, an evidence based trauma-treatment, with parents who are involved in the child welfare system. Just as in the case that Julie presented yesterday we have found that these caregivers have severe trauma histories and many many ACEs.
In case you haven't seen this: the Vermont legislature is considering a bill that would set up ACE screening in the state's health care system.
One point made by Julie Campbell at the panel yesterday on helping people overcome experiences of toxic stress was on understanding "It's not what's wrong with you, it's what happened to you" in context of shifting from shame to understanding. Is this an idea that can be used to move systems forward? In changing our view? What would need to happen to do that?
Philadelphia has already started, with some success, educating about the importance of this issue at all levels - top officials, providers, and most importantly, parents. We mostly use numbers and figures to make the point. Although this needs to continue, we now need to provide constant examples of HOW it is done in various settings. This involves anecdotes, storytelling, etc., penetrating multiple forums.
A huge challenge is going to be to change the disciplinary parenting style that is so deeply rooted in our culture. This is particularly challenging due to the multi-generational nature of parenting. Parents often raise their children the way they were raised. In our society, when we want to correct negative behavior, most of us immediately think of discipline, punishment, and consequence. We need to begin to steer people away from the idea that negative sanctions will promote positive behavior, and this will come from, as Ms. Woloszyn mentioned, education and support for parents.
However, just because these supports are present, does not mean that parents are going to use them. How can we create incentives so that parents will get involved in parent education programs, particularly for the parents who think the disciplinary approach is the most effective approach, and do not think they need to be educated?
It seems to me that educating more people--primary care providers, early childhood professionals, k-12 staff, social service providers, etc.--about trauma and ACE's, and how to approach working with children and families who have experienced trauma, is one of the main places to concentrate efforts. All of these groups gather for professional development, and a workshop on trauma and ACE's should be a part of the curriculum for each of these groups.
I think it could be a combination of both grassroots and institutional. For example, my organization, PCCY, has trained early childhood professionals and school staff on the behavioral health system in general, and how best to connect children to it (including information on health insurance). So little by little, and with the efforts of others, as well, we've been able to spread the word more broadly about behavioral health and put resources into people's hands to assist them in their work with families.
The same thing can happen with getting more of the community to be trauma informed. If several organizations commit to some small piece of educating and being a resource, we can really make a big difference. As Joel Fine mentioned, there are organizations that have been and continue to do this kind of work, so perhaps the bigger question is: How can we support that work and what more is needed to advance it?
The institutional level work needs to happen simultaneously-- to leverage more resources, and establish more systemic approaches to trauma-- to piggy back on what Sean Halloran said.
The interconnectedness that you suggest is truly imperative, and communication between systems is paramount. One barrier is the "privacy" concern but in reality the labeling as a "public health" issue can allow systems to talk more freely.
We have an extraordinary moment before us here. Yesterday's event framed the issue of trauma and the effects of toxic stress so well, but it is now incumbent on the participants to take the next steps. I agree with strategies that include the sharing of narratives and storytelling (Julie Campbell's example yesterday was clear and inspiring), but we also need to engage and implore our payors and policy makers to include ACEs as a routine part of all health screening. The link between ACEs scores and physical health outcomes is clear. While no one would disagree with the moral imperative of helping children overcome trauma, it becomes less clear when we ask "whose job is it?" or "who is going to fund this?". As was pointed out so many times yesterday, it is the entire community's responsibility, and I believe we may need to be more forceful in opening some of those doors.
Does a map/flow chart/list exist that shows what systems an "average" child in Philadelphia interacts with? I realize that every child is different but I am trying to think what systems should we prioritize first. How can we impact the most children at once?
Sorry for this spammy post, but: I think that a greater effort needs to be made to change public attitudes as well. Obviously this needs to start with the professions, as noted above, but it can't be limited to them. One of the hardest things about growing up with trauma is that you feel defective and isolated, and other people often treat you that way, too. As a traumatized child it gets harder to establish and maintain productive/trusting relationships, even though traumatized children need these very much. You feel angry and frustrated at your inability to connect with others, or to deal with common life situations the way "normal" people do. You're often given the message (both by family and by others you come in contact with) that this stuff is just ordinary life and you should be able to deal with it; yet you are very much aware of your own inability to do so. Obviously we should emphasize prevention and therapy so that problems are less likely to develop, but it's far too late for many children to avoid them. They are then labeled as mentally ill or some other term that takes away the legitimacy of their reactions and experiences, rather than being treated as people having a perfectly normal response to trauma and/or chronic stress. Even well-intentioned efforts to help usually give these children the message that something is broken about them that other people are trying to fix. I guess what I'm trying to say is that the denial by almost everyone of the legitimacy of your reactions can do at least as much damage as the initial trauma. I believe personally that this is often what leads to depression and associated reactions -- the dichotomy between how injured you feel and the disregard of others. This is especially the case with chronic stress, in which no specific event seems like a big enough deal to "cause" so much damage.
Too often, comprehensive support and guidance are expensive and difficult -- and however well-intentioned we are, they will probably always be more so than one-off treatments or symptom control. But all children want friends, interest, a kind word, acceptance by others. So the more people who understand how things really work -- whether they're doctors or social workers or teachers or parents or even just the other kids in your class -- the better, and the fewer children who feel both traumatized and rejected by society at large.
I think what is critically necessary is better integration of systems. This is a concept that is very important in behavioral health and I think it applies here. Screening for ACEs in routine medical check-ups is a great step and something that I hope gains more and more momentum. However, there also needs to be be better communication and interconnectedness among various social service systems. Obviously, it is much, much easier to say that than it is to implement it, but conversation is the first step towards action. When the conversations take place, ideas can follow, and then actionable items can emerge.
Katherine thank you! I appreciate that you have reminded all of us that as we think about large macro systemic solutions we must also keep in mind these day to day interactions with children, adults, and families who have experienced trauma and how they can contribute to retraumatization. I completely agree with you that often children who have experience trauma are labeled and marginalized because of their behaviors, which as you point out, are legitimate and normal reactions to trauma. Personally, I have really used the key question "What has happened to you" as a mantra when I find my self reacting or judging someone else's behavior negatively.
Given the growing momentum around these issues, how do we go about 1. advancing the knowledge of ACEs and the effects of trauma in child-serving systems, and 2. how can we focus on creating a trauma-informed culture that will support a safe environment for both kids and staff? Creating this safe environment in all child-serving systems is crucial for prevention.
I just followed the RWJF Google Hangout on Community Health Rankings today (see #RWJF1stFri on Twitter) and @KatyLoomis from GSK reported the finding about Philadlephia being the lowest ranking county in health. The resource discussed is found on here: County Health Rankings and another recommended resource is here: Community Commons data mapping Will sharing data help the movement forward? Or is the change motivated from a different angle?