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The Adverse Childhood Experiences (ACEs) module, included in Behavioral Risk Factor Surveillance Systems (BRFSS), has become an important tool for directing health policy, planning health programs and creating early intervention and prevention strategies. According to the CDC, BRFSS data is utilized by approximately two-thirds of states to direct health-related legislative efforts. The 32 states that have implemented the ACE module in their BRFSS have generated a series of recommendations to promote trauma-informed norms, policies, and programs. These recommendations are similar across states and are actionable by a wide range of governmental and civil service organizations at the national, state, and local levels. For the purpose of this review, we summarized the recommended actions presented by multiple states into the following list:

Education

  1. Increase awareness about ACEs and their impact on health and wellness
  2. Train providers and the public on brain development, adverse childhood experiences (ACEs), and resiliency
  3. Teaching resilience and promoting positive family communication, routines, and habits as powerful protective and healing factors for children with ACEs

Collect ACE Data and Identify Solutions

  1. Collect annual state-level data on the prevalence of ACEs
  2. Develop a thorough inventory of existing agency and community efforts to reduce ACEs and support resilience
  3. Support efforts to identify evidence-based practices and tools to identify and respond to ACEs

Trauma Informed Systems

  1. Develop a trauma-informed human service system that is based on prevention and early intervention strategies

ACE Screenings

  1. Promote screening and monitoring for ACEs in primary care offices and public health clinics

Home Visitation and Early Education Programs

  1. Expand home visiting programs and Expand and strengthen quality early childhood programs

Capacity Building

  1. Enhance the capacity of communities to prevent and respond to ACEs by: a) building collaborative leadership to form a vision and support change and b) increasing social connectedness, encourage community mobilization, and facilitate access to supports and services.

Education

  • Increase awareness about ACEs and their impact on health and wellness
  • Train providers and the public on brain development, adverse childhood experiences (ACEs), and resiliency
  • Teaching resilience and promoting positive family communication, routines, and habits as powerful protective and healing factors for children with ACEs

 

As Dr. Robert W. Block, a former president of the American Academy of Pediatrics, posits that ACEs are the “Greatest unaddressed public health threat facing our nation today.” As we continue to face this on-going threat, an emerging network of community leaders, health care and social service professionals, and educators are working to raise awareness of ACEs and their impact on health and wellbeing. They view ACE education as an important, foundational element of trauma prevention and intervention efforts. Dr. Robert Anda, a co-researcher from the original CDC-Kaiser Permanente ACE study, calls for a “National education program for the general public and for people who provide services in all the systems.” Outlined below are three strategies used by state and national organizations to introduce ACEs into the public consciousness. These strategies target individuals, communities, and providers in an effort to create broad understand and support for the movement to build a trauma-informed nation.

Strengthening individual knowledge and skills involves “transferring information and knowhow to increase an individual’s resources and capacity for preventing injury or disease.” In ACE education initiatives, these ‘individuals’ include the parents of children and adolescents. When parents understand ACEs and associated outcomes, they will be better equipped to prevent their children from being exposed to trauma. For children who have already been exposed to trauma, parents should be educated on resilience building and strategies to develop protective factors in their children’s lives to prevent adverse outcomes.

Community education is an effective strategy for building community resilience and mitigating the effects of adverse community environments. The Building Resilient Communities (BRC) Coalition, located in the George Washington University Milkin Institute Schools of Public Health, describes adverse community environments as the, “many traumas may be linked to the lack of resources or increased threats (mental, physical, economic) at the family and community levels. The effects of adverse childhood experiences are compounded when they occur in the context of adverse community environments” Effective community education strategies inform groups about health and social issues while also building widespread support for healthier behavior, norms, and policy change. According to Dr. Anda, when the public has a broad understanding of trauma and violence, “they will demand changes in policy and practice.”

It is also essential that we educate providers on ACEs to improve their understanding of trauma and prevention. Providers (e.g. medical professionals, educators, child welfare workers, lawyers, etc.) can serve as valuable advocates and educators in the ACE movement as they have influence within their fields of expertise and opportunities to transmit information, skills, and motivation to patients, clients, and colleagues. Institutions of higher education are playing an increasingly significant role in creating a trauma-informed provider workforce. The need for trauma-informed curricula comes from the realization that many emerging professionals will interact with clients who have been exposed to significant trauma. To successfully serve this population, providers must be able to effectively identify, understand, and respond to symptoms of early childhood adversity.

In 2016, Philadelphia ACE Taskforce (PATF), in collaboration with Mobilizing Action for Resilient Communities (MARC) grant program, the Thomas Scattergood Behavioral Health, Foundation, the Health Federation of Philadelphia, and ACEs Connection, conducted an environmental scan of trauma education programs in the U.S. While their list of programs is not exhaustive and more institutions may have added trauma-related curricula in the two years since the scan was conducted, it reveals a growing, yet uneven, trend of trauma education.

 

Figure 1. Number of schools that have trauma education components by region of country

Figure 2. Number of trauma based programmatic offerings by field

Like ACE education initiatives, the Middlelayers platform is designed to target individuals, communities and providers to introduced them to the concepts of trauma and resilience. Yet, Middlelayers goes a step further than most education programs. Accessible on any smartphone, computer, or tablet, the platform makes ACE information readily available so that a family in Florida and a social worker in Alaska can receive an ACE education simultaneously. Instead of speaking about ACEs in general terms, users learn about ACEs in the context of their own lives. Users can take an ACE survey to calculate their ACE scores and view associated risk factors, thereby directly illustrating for them the connection between trauma and poor health. Furthermore, while many ACE education programs end after instruction, the Middlelayers platform guides users as they translate their knowledge into action. Our technology gives individuals the tools to identify, locate and access protective factors and providers and community members a platform through which they can contribute to resilience building.