OVC Provider Forum Transcript

Implications of Adverse Childhood Experiences for Practitioners
Dr David Corwin, Dr James Henry  -  2014/4/23
If you could redesign the child welfare system in the United States, (knowing what we now know about trauma and brain development) what would the new system look like?
1.  Dave Corwin, MD
 Here are some additional resources about the ACE Study and other childhood traumas: http://www.cdc.gov/ace/index.htm http://acestoohigh.com/resources/ http://robertandamd.com/ vjfmdsdca@mac.com www.avahealth.org www.acestudy.org acesconnection.com http://www.cdc.gov/ace/ www.aap.org/medhomecev/education www.developingchild.harvard.edu www.nctsn.org
2.  Jim Henry
 Yes there are trauma screening tools for nonprofessionals to use. The Trauma Screening Checklist is being used by teachers and aides to identify potential trauma history and subsequent behaviors. If you are interested you can email me and I will send it.
3.  Betty W. Coyle
 Are there trauma screening tools that can be used by non-therapist professionals that can identify domestic violence and child sexual abuse trauma?
4.  Dave Corwin, MD
 The is a recently published study that supports early investment in preschool children: The citation is Science: Early Childhood Investments Substantially Boost Adult Health, 3/28/14, pages 1478-1485.
5.  Jim Henry
 Part II Trauma assessment includes neurodevelopmental testing, pragmatics, caregiver input through ethnographic interviewing and completion of standard behavioral instruments (especially the Trauma Symptom Checklist for Young Children 3-12 years) and a psychosocial interview of the child to gain their perceptions of their trauma and view of the world. A strong feedback loop between the clinician and caseworker would occur to inform case planning for the child.
6.  Jim Henry
 Workforce resiliency through addressing secondary trauma stress and organizational stress would also need to be a priority. Identifying, acknowledging, and addressing secondary traumatic stress along with creating organization safety are essential to maintain a healthy workforce that is able to positively interact and respond to the needs of maltreated children and their caregivers. In addition responding and addressing critical incidents in child welfare is foundational for caseworker quality work performance.
7.  Jim Henry
 Treatment would focus on building resiliency of which counseling would be an important strategy to include when trauma assessment reveals traumatization, whether it meets the criteria for PTSD or not. Case planning would target building relatedness for the child, developing mastery/competency, building affect regulation skills, and strengthening self esteem. Children and parents would receive evidence based/supported treatment to process their trauma, but all professionals would prioritize contributing to the primary area of resiliency.
8.  Jim Henry
 PART I The system would move from being event driven only (actual maltreatment) to include being impact driven (the effect of traumatic stress). The maltreated child would be screened for traumatic events along with potential impact to behaviors, mood, and functioning. There are several examples of trauma screeners including the CANS-T and the Trauma Screener Checklist that can be utilized by clinicians and/or child welfare caseworkers. Those children screening positive for trauma (depending on the threshold of the screening tool) would be referred for a comprehensive trauma assessment.
9.  Dave Corwin, MD
 It would start with significant investment in primary prevention using the best evidence-based models that we have. These include home visiting, Safe Care, Triple-P and others. Our investment in early childhood and helping parents succeed would be a major local, state and federal initiative as Professor Heckman advises.
Given that most abusers are related to their victims, what would you suggest to help protect children with disabilities against abuse or neglect? These kids are both more at risk and less able to have access to other adults who might help.
1.  Janine
 Are you suggesting that all parents of children with disabilities be encouraged to fill out eval forms, in the same way they might fill out other forms involving their kids?
2.  Jim Henry
 In addition to child screening, parents of the children would be screened for traumatic history and potential impact to functioning. Those screening positive would receive a trauma assessment similar to the child trauma assessment, although instead of caregiver forms there would be self report measures on trauma.
3.  Dave Corwin, MD
 Educating all those who work is disabled children about their increased risk of maltreatment and how to recognize early signs of abuse.
Does the instance of an ACE increase the likelihood of adult victimization? Are there higher likelihoods for particular offenses?
1.  Dave Corwin, MD
 We know this is true for child sexual abuse. We know less about some of the other ACEs.
2.  Jim Henry
 As the number of ACE factors increases so does the likelihood of adult victimization because trauma begets trauma through substance abuse, depression, and increased sexual partners. Each of these areas has secondary risks for further victimization. If a child is sexually abused they are 6x more likely to be sexually abused in the future than a child who has not been sexually abused. The likelihood of them being raped as adult increases tremendously as well.
Is there "technical assistance" available to help integrate the ACE study into Public Health and Mental Health/Addictions programs?
1.  Dave Corwin, MD
 There is a very good AAP webinar posted at: www.aap.org/medhomecev/education that provides information for pediatricians about integrating this into primary care pediatrics.
2.  Pam Wessel-Este
 In WA, our state Dept of Health as well as several other state level agencies are providing support, resources and TA around ACEs, including provisions for ACEs training and education efforts supported by state block grants. There is also a public-private partnership providing some support, and two Universities contributing to research and funding. Counties are getting very engaged, too.
3.  Dave Corwin, MD
 The Academy on Violence and Abuse is working to increase the awareness and skills of health providers working to address histories of violence and abuse in their patient's backgrounds. You can find more information about the Academy, AVA at www.avahealth.org
4.  Jim Henry
 The ACES has challenged all systems involved with children and adults to begin developing new programs to address the impact of early childhood adversity and trauma. Unfortunately, the response has been slow. The most significant efforts nationally have been led by the SAMHSA funded National Child Traumatic Stress Network which is a network of over 160 funded or previously funded sites to rise the level and access to care for children who experience trauma.
What do we know about the sensitivity and specificity of using ACEs to predict health and behavior outcomes?
1.  Dave Corwin, MD
 We need a lot more research to help us answer many of these questions. There has been too little research funding in this area. Hopefully, that will change.
2.  Jim Henry
 There is significant findings about the long term health risks for those with at least four or more endorsed ACES factors. These include increase suicide, diabetes, multiple sexual partners and early death. Those with 6 or more ACES factors are likely to die 20 years earlier than those with no ACES factors. Those women with at least 5 or more ACES factors have a five times the risk of depressive disorders
What the implications of ACE for primary prevention strategies?
1.  Jim Henry
 Part I. There are significant implications for primary prevention, yet change has been slow in making those changes despite the ACES data. To intervene early in children's lives to prevent long term health and psychological harm must be a priority. However, too often our heads are in the sand as we don't take an active role to address those issues. Adults and our systems employ avoidance and a cultural paradigm based on the belief that if children or adults want to change they can. There is little to no recognition of how trauma changes the brain and then compromises executive functioning which can seriously impact problem solving.
2.  Dave Corwin, MD
 The ACE Study, its state level similar findings from the BRFSS now being implemented in 21 states provide the most compelling evidence that we need effective prevention of child maltreatment and other preventable childhood traumatic/toxic stressors.
I am interested in hearing the latest information about how readily accepted is the ACE study becoming among the medical community?
1.  Dave Corwin, MD
 Health has been one of the more resistant sectors with regard to the ACE Study findings. It threatens the whole fee for service way of doing business. Under health reform, with capitated healthcare systems, prevention is finally incentivized and I hope that this information begins to take hold. Dr. Felitti's latest list of ACE publications can be found on the AVAhealth.org website under the "ACE Study" tab on the navigation bar. There are now more than 80 publications about the study findings.
2.  Jim Henry
 The medical community is beginning to recognize and address the ACE study within the last year with a AAP position paper by Dr. Jack Shankoff on Toxic Sress and the calling for screening on all children using the ACES screening instrument.
Given last year's[recently updated] message from HHS Secretary to state CW Commissioners about importance of trauma-informed care among bpth public systems and private providers,what is likelihood of any significant infusion of federal funding to states to support this initiative from primary prevention through intensive intervention services? And what assumptions can we make aboutsupport for serving/ treating parents/family members as well as victimizerd children from thisinitiative?Basically this is both a service commitment and funding sustainability question.
1.  Dave Corwin, MD
 There are some free edited videos regarding the ACE Study that you can download from the AVA website. One is a 3 minute preview. There is a 8 minute summary designed to show policy makers or other leaders with little time to listen and a 15 minute version that is good for an hour class or lecture. The AVA ACE Study DVD is 4.5 hours of excellent information about the ACE Study. You can find all of these on the www.avahealth.org website. The DVD is not free but is given to all new members and there is also an institutional subscription available so that all those with access to an institution's intranet can access all the videos on the DVD.
2.  Dave Corwin, MD
 To help find out what you can do to help, see the www.avahealth.org website. Plese consider joining it and other organizations working to advace this field.
3.  William Webb
 NJ DCF Commissioner Allison Blake recently created a new position of Director of Strategic Development to boost/integrate state [and provider]efforts around performance=based contracting,use of EBP's and infusing trauma-informed care. Are there other states further along/already implementing trauma-informed principles/practices within state systems and among providers?
4.  Jim Henry
 Part II: The paradigm shift to trauma informed is slow but headed in the right direction through ACF and SAMHSA funding. However, traditional child welfare system are not trauma informed. It will take considerably more money and increased state commitment to become trauma informed and better serve our children and parents. In Michigan due to both our ACF and SAMHSA grants we are moving to be trauma informed with a newly developed state partnership with our agency.
5.  Jim Henry
 The Administration for Child Family of HHS has released three rounds of large grants to develop trauma informed child welfare systems through increased screening, assessment, progress monitoring and child well being. The feds just released another ACF two weeks ago on child well being in substance abusing families. Bryan Samuels the former ACF director, who left a few months ago, was a champion for developing these new trauma informed practices.
6.  William Webb
 What can we as collective practitioners do to " make the case" compelling and advance it based on what we do know already about science/ success of service impact and costs/consequences of unaddressed trauma?
7.  Dave Corwin, MD
 It is still very early in our evolution toward trauma informed care. The federal departments and agencies appear very interested but there is a lot of work that remains in providing the funding and the science needed to integrate trauma informed practice into health and other sectors like education where it needs to also be addressed.
What are some examples of fundamental affect regulation skills that you think could or should be taught to pre-schoolers, elementary age kids, and junior high and high school children?
1.  Jim Henry
 There are several affect regulation treatment modalities for children that we have used that we believe are excellent. TARGET (Ford, 2007) is specifically designed for adolescents to build affect regulation skills utilizing a brain based approach. It is now evidence based and has been very successful for juvenile justice youth in learning to regulate affect. SPARCS is another excellent curriculum for adolescents. For younger children Occupational Therapy Interventions are excellent for building affect regulation skills. TF-CBT has a relaxation component as foundational to affect regulation skills.
2.  Dave Corwin, MD
 The NCTSN, National Child Traumatic Stress Network has a website which includes much information about evidence-based treatment. Your question is best addressed by those resources. www.nctsn.org
ACEs are linked to medical and behavioral outcomes, but little is known on how ACEs predict future behavior. (RCTs are understandably difficult.) Are there prospective longitudinal studies where ACEs are causal factors for future behavior? Are researchers comfortable using ACEs as predictors of behavior (such as crime?) What policy implications are there for identifying ACEs in children to prevent negative behavioral outcomes?
1.  Jim Henry
 The ACES has significant policy implications to address potential future criminal behaviors given that if you have 6 or more ACES factors that you are 4600X more likely to be an intravenous heroin user. The ACES is not causal but certainly strongly associated with increased negative health and behavioral outcomes including substance abuse and depression. Further the estimated criminal just cost per victim of child maltreatment is $6700, $8000 special education, 32,000 in childhood health care costs, 10,000 in adult medical costs, and 144,000 in productivity costs.
2.  Dave Corwin, MD
 Using ACEs to predict future behavior is a stretch and possibly unfair to those with ACEs. We already know that soldiers who develop PTSD have higher rates of maltreatment in their childhoods but it would be unfair and unwise to screen people with high ACEs out of military or any other kind of service or work. We should use this knowledge to help people live healthier lives not to categorize them and discriminate against them!
It's tempting for policymakers to want to embrace the ACES findings by mandating or encouraging health care providers to routinely screen all adult patients. Some national advocates have said that the screening of adults in and of itself is an appropriate intervention. I notice you recommend that for children the initial screening is more a means to get children experiencing trauma into a more thorough trauma assessment and supportive services. Is there a difference in recommendations for implementation of ACES for children vs. adults?
1.  Dave Corwin, MD
 There needs to be a continuum of care for those who have experienced ACEs and adult traumas as well. We do not have enough therapists trained in evidence-based therapies to treat all traumatized adults. Nor do all adults probably need such treatment. Just acknowledging the ACEs or other traumas is the beginning. Self care and self help is another step. Treatment should be used for those suffering significant symptoms and problems related to their earlier traumas.
Related to mass trauma events - Are there any studies outlining the efficacy of protocols such as the NOVA model, CISM or Psychological First Aid?
1.  Jim Henry
 Psychological First Aid (NCTSN) is being utilized across the world. There is significant anecdotal data indicate it is extremely valuable in reducing later PTSD symptomology and returning to pre-trauma functioning. There are current studies but I am not familiar with any released quantitative studies. I am not familiar with the other models.
I know that the Department of Children Services are responsible for the children's well being if there are any allegations of abuse in the home but what other laws are in place to also help protect the children in these situations.
1.  Jim Henry
 Unfortunately, the only other are criminal laws that each state has regarding harm to children. However, these laws are based on physical harm and not psychological harm or the threat to well being which can have even more long term neurodevelopmental harm than physical harm.
2.  Dave Corwin, MD
 Law enforcement is also responsible for investigating crimes against children. Social services is vested with protecting abused children from further abuse. Law enforcement seeks to determine if crimes have been committed and refers to prosecution which decides whether the evidence support criminal prosecution. There are also rules and regulations designed to protect children like the new USA Swimming guidelines for protecting children in their programs developed by Victor Vieth of the Gundersen National Child Protection Training Center.
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