1. Addressing Childhood Trauma: Public Policies to Improve Coordination, Prevention, and Response December 1, :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

2. 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

3. 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!

4. 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

5. 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

6. Data Resource Center

7. 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);
Source: Bethell, C 2016

8. 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

9. 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 % Uninsured

10. Maternal Health and Child Health

11. 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

12. 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

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

14. 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

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

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

17. How we connect

18. 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). [
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.

19. 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

20. 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

21. 13 Example State Innovations (States Exploring Options Identified from 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)

22. 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

23. 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

24. 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.

25. 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”

26. 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

27. 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.
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
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

28. 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 (
Source: Bethell, C 2016

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

30. 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

31. Source: Bethell, C 2016

32. 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);
Source: Bethell, C 2016

33. Public vs. Privately Insured Children Higher ACEs, Similar Across State Variation (

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

35. 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

36. 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

37. 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