Addressing Childhood Trauma: Public Policies to Improve Coordination, Prevention, and Response December 1, 2016 12:00-1:30PM 188 Russell Senate Office Building Christina Bethell, PhD, MBA, MPH Johns Hopkins Bloomberg School of Public Health Child and Adolescent Health Measurement Initiative Department of Population, Family and Reproductive Health

For Child & Family Health (using family centered data and tools) Identify Shared Transformative Goals For Child & Family Health Promote Early and Lifelong Health of Children, Youth and Families (using family centered data and tools) Transformational Partnerships Actionable Data & Data-Driven Tools Inspire and Inform Bethell, C 2016

Promoting early and lifelong health leveraging prevention and human development sciences. A Critical Goal: Optimize the capacity of Medicaid to drive and ensure efforts at the individual, family, community and systems levels to effectively address social and emotional determinants of health, like ACEs, to promote positive health resilience and well-being among children, youth and families. ….and catalyze and epidemic of health for generations to come!

Hard Science Reveals Requirements for Healthy Development and Well-Being Positive Health, Resilience, Protective Factors and Risks Social and Emotional Development Safe, Stable, Nurturing Relationships If regulation requires connection—what does “self-regulation” mean? Source: Bethell, C 2016

ACEs Impact Multiple Outcomes General Health and Social Functioning Relationship Problems Married to an Alcoholic Poor Self-Rated Health Smoking Alcoholism High perceived stress Difficulty in job performance Hallucinations Promiscuity High Perceived Risk of HIV Depression Obesity General Health and Social Functioning Sleep Disturbances Risk Factors for Common Diseases Mental Health Memory Disturbances Poor Perceived Health ACEs Illicit Drugs Anxiety IV Drugs Panic Reactions 5 categories are… Examples of these categories are… But wait, there’s more… It is easy to look at this slide and to be overwhelmed, but I see potential because if all of these diverse outcomes are associated with ACEs, there’s at least the potential to impact upon all of these public health crises by preventing and addressing childhood toxic stress. Another way to breakdown this slide is to look at these 6 risk factors, which are essentially unhealthy lifestyles that are known to be maladaptive stress reduction techniques. THEY ARE ALL WAYS TO ESCAPE, even if only temporarily, THE STRESS OF LIFE. And most of the rest of these adverse outcomes can be attributed, at least in part, to these unhealthy lifestyles. So, this forces us to look at adolescent and adult health in a completely different manner. Are we going to continue treating all of these unhealthy lifestyles and symptoms of unmanaged stress, or are we going to pro-actively address the childhood antecedents – the root or distal causes? Which reminds me of the following public health parable… Prevalent Diseases Sexual Health Multiple Somatic Symptoms Poor Anger Control Cancer Liver Disease Teen Paternity Fetal Death Skeletal Fractures Chronic Lung Disease Teen Pregnancy Unintended Pregnancy Sexually Transmitted Diseases Early Age of First Intercourse Ischemic Heart Disease Sexual Dissatisfaction 5

Data Resource Center

Prevalence Among US Children (2011-12 National Survey of Children’s Health) Prevalence of 2+ (of 9) ACES: 16.3% (UT) – 32.9% (OK) Bethell, C, Newacheck, P, Hawes, E, Halfon, N. Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. (2014) Health Affairs Dec; 33(12);210-2016 Source: Bethell, C 2016

Equally Unequal: Similarities of Impact Across Income Groups Prevalence of Emotional, Behavioral of Developmental Problems Among Children with 4+ ACEs: By Household Income Rich or poor The withholding of love Pierces May you be led to the mysterious transfiguration this piercing can allow And open to the truth from within like the nautilus closing off all former layers And slowly, patiently rising up into the love that always was Mirrored or not Always was Always will be Excerpt from “Breaking Ground” Christina Bethell Bethell, C 2016

Nearly 2/3 of children with public sector insurance coverage carry ACEs, such as physical and emotional abuse and neglect, substance abuse or mental illness in the home, justice-involved family members, exposure to violence, and extreme poverty. 63.8% Public. 36.6% Private. 58.4% Uninsured

Maternal Health and Child Health

School Engagement Rate Among Children With Special Health Care Needs Exposed to 2+ Adverse Childhood Experiences: By Demonstration of Resilience “You can go good places with your mind if you can’t go good places with your body. “ Stephen Porges, PhD Professor Emeritus, University of Illinois at Chicago. Director, Brain Body Center in the Department of Psychiatry. Author: The Polyvagal Theory Bethell, C 2016

Shining a light on ACEs is more than a “Courtesy Alert” “In my beginning is my end.” (?) T.S. Eliot, Four Quartets “Where you stumble, there your treasure lies” Joseph Campbell Bethell, C 2016

The Public Sees A Problem April 18, 2016 National Poll Results

Relationships At the Core of Adaptive Systems: (Masten, ‘14) Safe, stable, nurturing Effective parents and caregivers Connections to other competent and caring adults Child - Awareness of sensations, feelings, meaning; self soothing - Problem solving skills; resourceful; - Positive beliefs about self - Beliefs that life has meaning; goals --Spirituality and faith; hope Community & Environment Socioeconomic sufficiency Pro-social culture and peers Effective teachers/schools Safety and trust Collective efficacy and capacity for problem solving Source: Bethell, C 2016

Maslow Rewired: The primacy of safe, stable, nurturing relationships to physical and mental health throughout life Source: Bethell, C 2016

When a baby feels safe, they explore and if a baby explores, they learn. Source: Bethell, C 2016

How we connect

The Critical Need for Translation, Discovery and Capacity Building in Medicaid The good news—ACEs and trauma are recognized as roots for poor outcomes It the CMS July 11, 2013 State Medicaid Directors letter, CMS encouraged states to develop models, policies and practices to prevent and mitigate the early and lifelong impacts of the trauma that can arise through exposure to adverse childhood experiences (ACEs). [https://www.medicaid.gov/federal-policy-guidance/downloads/smd-13-07-11.pdf] The current status: Without purposeful action, little progress will be made Many State Medicaid programs and systems have begun to focus in these areas, but a coordinated and supported agenda and learning network is needed to specify and translate best practices, innovate and advance policy.

An Essential Point: Healing is Prevention Whole Person, Whole Population Well-Being Mandate Culture Shift to a Neuro-informed Possibility, Growth and Equity Mindset Actionable Metrics Shared Across Policy and Practice Spheres Accessible, Translated Effective Methods addressing Mechanisms for Prevention and Healing Trauma Concrete “Common Elements” Models & Prototypes and Learning Engine for Refinement and Scaling The shifts in mindset, metrics, methods and models needed to effectively heal, prevent and attenuate the long reach and impact of ACEs are in keeping with broader focus on social determinants of health, but ACEs and promoting resilience are distinct. Bethell, C 2016

Key areas of work Bethell, C 2016 Evidence Synthesis and Communication Engine Innovation and Rapid-Cycle, Citizen Science Learning Platform Open Source Hands on Help, Data, Tools and Training Engage and Empower Enduring Cadre of Champions Across Sectors Search, Summarize, Celebrate and Scale Success Bethell, C 2016

13 Example State Innovations (States Exploring Options Identified from 2016 Futures Without Violence Report)   Use Medicaid Flexibility to Design Trauma-informed Health Homes (DC, ID, IA) Adding Trauma Services to Medicaid Benefits Package (CN, ID, MI, OK, AZ, NE) Strengthen, Enhance and Enforce EPSDT Benefit (CO, IA) Cover Home Visitation Under Medicaid Blend Funding Sources to Provide Wraparound Coordination and Services (WI, AK, CN, CA) Co-locate Financing of Health Care, Behavioral Health and Other Social Services (MI)

13 Example State Innovations   7. Implement the State Option for Peer-to-Peer Training & Supports (TN, GA) Support Two-generation, Family-based Solutions Foster Collaboration with Schools and Early Care Support Enrollment for Foster Care Youth and Homeless Youth Support Continuous Enrollment for Justice-involved Populations Expand Scope of Practice Laws in the State

The 7C’s of Translation Bethell, C 2016 Costs and Payment Coverage & Coding Costs and Payment Contracting & Accountability Capacity & Training Credentialing & Integration Coordination Within and Across Communication Within and to the Public & Consumers The 7C’s of Translation Bethell, C 2016

7C’s of Policy and Practice Translation 1. Coverage & Coding--along the continuum of primary prevention, secondary prevention and complex trauma treatment; to support screening, care coordination and codes to identify Developmental Trauma Disorder (National Child Traumatic Stress Network). 2. Contracting and Payment- test payment models that enable systems capacity to address social determinants of health overall, and ACEs in particular. Requires integration of trauma-informed behavioral health and community support services 3. Contracting and Performance Measurement-install contracting provisions and performance measurement methods to promote provider, health plan and related systems innovation around social determinants of health and ACEs. 4. Capacity & Training- identify and promote core competencies, install trauma-related Continuing Medical Education (CME) requirements. Align information technology (IT) systems and tools and define practice work flows and team models support goals.

7C’s of Policy and Practice Translation 5. Credentialing & Integration—specify the role and training for nontraditional providers, like peer-to-peer, family-to-family and community health workers. Align credentialing, supervision and payment models. 6. Coordination- envision and deploy delivery system models that coordinate data, teams, services and supports and collaborate in consistent public education and best practices 7. Communication—Engage children, families, communities, providers and leaders around a common communication platform and shift the dialogue to align with the “no shame, no blame, science-based ACEs framework”

Nearly 50 Years of Research Linking Well-Being to Safe, Stable, Nurturing Relationships and Stress 1968 Herbert Benson of Harvard 1976 Eugene Gendlin from University of Chicago publishes “Focusing” which lays out a 6 step process for changing the way thoughts and emotions impact the body. 1986 University publishes The Relaxation Response John Bowlby publishes Attachment and Loss Norman Cousins (UCLA) publishes Anatomy of an Illness in the NEJM Richard Davidson publish first neuroscience paper evaluating the effects of meditation on brain physiology and attentional and affective capacities. 1975 1982 David Barker publishes landmark research and theories on the fetal and early life origins of health and adult disease, launching a now vital new field of study on the developmental origins of health and adult disease (DOHaD). Daniel Siegel publishes The Developing Mind textbook that integrates multiple streams of neuroscience, biologic and human development sciences into a coordinated theory called Interpersonal Neurobiology 1990 CDC/Kaiser Permanente launch the Adverse Childhood Experiences (ACE) Study to understand links between childhood social and emotional 1998 2000 Jon Kabat Zinn publishes bestselling Full Catastrophe Living --the first textbook describing mechanisms of stress on the body- mind and role of mindfulness-based stress reduction approaches to reduce pain and improve mental and physical health experiences and adult health. Former JHU NIMH scientist central to Nobel Prize winning discovery of the opioid receptor site publishes Molecules of Emotion documenting the molecular underpinnings of the mind-body connection. 1996 1999 The Institute of Medicine/National Academy of Sciences releases Neurons to Neighborhoods Source: Bethell, C 2016

Nearly 50 Years of Research Linking Well-Being to Safe, Stable, Nurturing Relationships and Stress Exponential uptake of ACEs Study and other accumulated findings lead to national, state, local and 2010 Nobel Prize winning Elizabeth Blackburn’s research team finds mindfulness meditation may slow the rate of cellular aging and extend life expectancy. 2012 2016 international efforts that include paradigm shifting “trauma-informed” initiatives that incorporate mindfulness-based approaches in schools, policing, medicine, social work, community, city and public health. The World Health Organization World Mental Health Survey Initiative documents impact of ACEs and other adversities across 21 countries, finding similar results as the CDC/Kaiser ACE study. The American Academy of Pediatrics Issues is first policy statement to pediatricians explaining and advancing the science and practice of preventing and addressing early childhood stress and trauma. The American Academy of Pediatrics will publish its first policy statement to US pediatricians on the use of mind-body methods to improve health of children and youth. 2011 2013-2015 The National Survey of Children’s Health includes questions about ACEs and resilience, providing first ever population based data for all US children, youth and families. North Carolina ACO specifically studies Community Resilience Model as strategy for chronic disease management Numerous high profile studies published linking early childhood investments to adult health Precedent setting lawsuit launched against CA School District giving children with social and emotional trauma rights under the American’s With Disabilities Act The US Centers for Medicare and Medicaid Services (CMS) issues its first (of several) State Medicaid Directors policy memos to advance screening for addressing interpersonal, social and emotional trauma in children served by Medicaid and child welfare systems in the US. Source: Bethell, C 2016

Integrating a Trauma Informed Approach With an Explicit Focus on Restoring Relatedness, Connection and Nurturance the widespread impact of trauma and understands potential paths for recovery Realizes the signs and symptoms of trauma in clients, families, staff, and others Recognizes by fully integrating knowledge about trauma into policies, procedures, and practices Responds re-traumatization by fully integrating knowledge about trauma into policies, procedures, and practices Resists Implementing trauma informed principles represents a paradigm shift Restoring relatedness and healing is prevention Source: Substance Abuse Mental Health Services Administration, National Center for Trauma-Informed Care (http://www.samhsa.gov/nctic/trauma-interventions)   Source: Bethell, C 2016

Mindsets to match the mandate Metrics to match the mindset Methods to move the metrics Source: Bethell, C 2016

To Beauty BACKGROUND ….and the translation of the science and practice of promoting positive health and healing for children, youth and families. Source: Bethell, C 2016

Source: Bethell, C 2016

Impacts on chronic condition status appear early in life. Bethell, C, Newacheck, P, Hawes, E, Halfon, N. Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. (2014) Health Affairs Dec; 33(12);210-2016 Source: Bethell, C 2016

Public vs. Privately Insured Children Higher ACEs, Similar Across State Variation (www.childhealthdata.org)

Flourishing and Adverse Childhood Experiences (US Children Age 6-17)

Flourishing and ACEs (2+) Among School Age Chidlren 44% CA to 25 Flourishing and ACEs (2+) Among School Age Chidlren 44% CA to 25.8 NY Zero ACEs: 62.9% ND to 44.7% DC

Strategic Recommendations on Proposed Legislation to Address Trauma Prioritize Possibilities There is more right with us than will ever be wrong! Strategic Recommendations on Proposed Legislation to Address Trauma (Durban-Hietkamp) Expand the scope of the legislation to include prevention and resilience-building as well as treatment; and address ongoing adversity as well as specific traumatic events. Prioritizing prevention and early intervention for high-risk individuals Identify and support the use of best practices by building on existing knowledge and structures. Address health care practices in a comprehensive and inclusive manner. Test new models using a variety of evaluation strategies, looking more broadly to support both evidence-based practices and emerging practices that show success. Disseminate best practices, but also focus on systemic change. Law enforcement coordinating center Faith leaders and other community figures Workforce

Developmental Trauma Disorder (DTD): National Traumatic Stress Network suggests that DTD is indicated with: dysregulation of a child’s stress response, as exhibited by symptoms, behaviors and, potentially, biologic measurements; (often categorized as mental health diagnoses now) internalized negative attributions and diminished hope and expectations for life; difficulty with self-esteem regulation; and functional impairments in key areas such as making social connections, participating in school, etc. Source: Bethell, C 2016