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A recipe for success defeating a hidden public health crisis

Early childhood education

It isn't news that people who experience serious trauma -- especially in childhood -- can struggle in many areas of life, from personal relationships to school and work. But an explosion of new research within the last twenty years is teaching us that Adverse Childhood Experiences (ACEs) can also take a longterm physical toll. 

As the Health Federation of Philadelphia explains in its Community Resilience Cookbook, the latest biomedical research shows that those who have experienced at least six out of a list of ten major adverse experiences may have their lifespans shortened by up to 20 years.

This is the kind of data that grabs the attention of scientists, policymakers and community members alike. Fortunately Philadelphia is at the forefront of tackling this hidden public health crisis.

The Philadelphia ACE Project -- which has called the Health Federation home since 2014 -- includes the Philadelphia ACE Task Force (PATF), a partnership of stakeholders, health and social work practitioners, and researchers. PATF's work includes the Effective Communication Strategies about ACEs project, working under the umbrella of the Health Federation, the Atlantic Center for Population Health Sciences, First Hospital Foundation and the Thomas Scattergood Foundation.

According to the Federation's Leslie Lieberman, director of special initiatives and organizational consulting, "PATF works to raise awareness about ACEs in Philadelphia...to prevent and reduce them, and to foster resilient communities." 

Those efforts include a series of local workshops with professionals and community members. Drexel associate professor and Sanctuary Model co-founder Sandy Bloom, M.D. is involved. So is Jonah Berger, Ph.D., a marketing specialist, associate professor at Wharton and author of Contagious: Why Things Catch On; he is working to create effective, easy-to-understand and motivating messages on the truth about ACEs. The PATF Community Education Workshop, headed by co-chairs Michael O'Bryan and Patricia Gerrity (director of the Stephen and Sandra Sheller 11th Street Family Health Services), is a sub-group of the initiative. 

O'Bryan is a program manager at the Village of Arts and Humanities and involved with a project called SMASH (Strawberry Mansion Sanctuary for Hope; part of the U.S. Attorney's Office of Eastern Pennsylvania's Project Safe Neighborhoods). He explains why just talking about the new science of ACEs can be difficult. Many of those affected resist a diagnosis, insisting "that's not traumatic, that's just the way I was raised," or they may brush the findings off because they survived serious trauma to raise a healthy family and shape a productive career. "There's this fear of pathologizing that people pick up," he argues.

In other words, it can be hard to explain the fallout of ACEs without individuals feeling stereotyped as sick or irreversibly damaged. Locally tailored, digestible ideas and straightforward language are important; so is emphasizing that ACE facts are about statistical risk, not imminent death. The movement is about recognizing, defining, combating and preventing community-wide statistical trends, not individual salvation. 

"That's why it's public health," insists Carolyn Smith-Brown, the Health Federation's administrative manager of special initiatives.

"It's not just, 'Gosh, if you could be a better parent…you could prevent this.' Nobody's thinking it's by your bootstraps…we're affected by our environment. There are a lot of things that are outside our control."

It's a lot to take in. Enter the Community Resilience Cookbook.

Using a landmark study from the 1990s, the Cookbook catalogues major types of ACEs: physical, sexual, and verbal abuse, and physical and emotional neglect. That study also examined five other indirect but still notable challenges: a household member who was addicted to drugs or alcohol or incarcerated, a mother who is a victim of domestic abuse, someone at home suffering from a mental illness, or the absence of a parent due to separation or divorce.

The impact of those hardships depends on the individual. "Trauma isn't the thing that happens. Trauma is the result," explains Smith-Brown. An event that doesn't traumatize one person might derail another person's life. 

O'Bryan makes an additional distinction between "trauma" and "relentless stress," both of which can cause health problems. 

"Trauma's very relational," he says. It has to do with experiences that elicit intense "terror, helplessness and fear…normally perpetrated by another individual." Rape or other assaults, neglect, or any kind of abuse are examples. Relentless stress, on the other hand, can encompass things such as being the caretaker for someone extremely compromised mentally or physically, having a family member incarcerated, joblessness, poverty, food insecurity or homelessness.

The first major study linking ACEs to adult health outcomes was performed by Kaiser Permanente's San Diego Health Appraisal Clinic, in partnership with the Centers for Disease Control and Prevention. From 1995 to 1997, over 17,000 Kaiser Permanente HMO members got a comprehensive physical and behavioral examination, and submitted detailed information about childhood experiences of "abuse, neglect and family dysfunction."

"There was a dramatic correlation between the number of these experiences that they'd had in childhood and their health," says Smith-Brown. This included problems such as diabetes, cancer and heart disease. "The things that traumatize us in the developing brain as children...end up leading to health outcomes as an adult." 
Why is this the case?

According to the Cookbook, a life full of serious stressors -- or a constant state of "red alert" in a dangerous home environment -- leads the body to pump out adrenaline and cortisol. Over time, this raises blood pressure, which in turn harms the heart and circulatory system. It also keeps glucose levels harmfully high, putting people at risk for Type 2 diabetes. 

Chronically high adrenaline and cortisol can also increase cholesterol or lead to issues such as osteoporosis, arthritis, gastrointestinal problems, depression, eating disorders and trouble fighting off infections. Autoimmune complications can also arise, leading to conditions like lupus, multiple sclerosis, rheumatoid arthritis, or pain syndromes like fibromyalgia. Ultimately, the research encompasses the field of epigenetics, which reveals the way factors in our environment activate our genes, and why the effects of large societal traumas can be passed down from one generation to the next. 

Since the Kaiser Permanente study put this research on the map -- spawning over 50 scientific articles -- the work has continued. Since 2008, 22 other U.S. states have done ACE surveys on the general population and found similar results. Other countries are taking notice, too, with ACE questionnaires being used or developed in Canada, China, Jordan, Norway, the Philippines and the United Kingdom. 

"There's an incredible amount of wonderful information that's just exploding," insists Smith-Brown. 

Philly had its own ACE study; the results were recently published. The study broadened the typical lens to look not just at factors in the home, but community-level factors like bullying, racism or feeling unsafe in the neighborhood.

This was accomplished under PATF and planning from the Institute for Safe Families (PATF's first convener); Philadelphia Health Management Corporation's research unit pitched in by adding the Philly ACE study questions to its own household health survey. 

Now that the information exists, how do we communicate it in the right way to the right audiences?

For example, connecting with policy-makers might mean emphasizing facts about neuroplasticity (the brain's ability to rewire its learned patterns and abilities), windows of child and adolescent brain development, and the underlying physical and psychological changes that affect the prefrontal cortex's executive function. 

"In the years of high school or middle school, where we have the opportunity to work scientifically and biologically with this part of the brain that needs some attention, we don't do it," argues O'Bryan. Community-based talks can take other tacks, often focusing on healing. And even if some people, particularly teenagers, aren't ready to engage in a conversation on healing, "they'll make a mad dash for it in an art class where they're writing poetry, or they're writing songs, or they're dancing. They want to get this autobiographical narrative out into a space where they can work with it and play with it."

Community-based talks have made it clear that the latest science isn't news to those already living it -- but people in struggling neighborhoods also have a sense that leaders and policymakers don't care about the issue. This requires an extra degree of sensitivity and affirmative messaging. 

O'Bryan is enthusiastic about the way many adult community members respond to the discussion, immediately wanting to connect the science to institutions that could benefit. 

"At Strawberry Mansion, when we talk to them about trauma theory, traumatic response and care, and what healing looks like, biologically, psychologically and socially," listeners leap to ask, "'Who's advocating for the kids in the juvenile justice system?…Is anyone talking about this?'" he recalls.

The research is so broad, adds O'Bryan, that you can reach different communities regardless of economic status, race, ethnicity, or religion. It's less about the individual's status and more about multi-generational "neighborhood ecologies" and associated "developmental risk." 

The power of neuroplasticity, given the right support, is encouraging. People are not doomed to bad outcomes because of experiences that may be outside of their control. O'Bryan can look at his own history as proof: His mother suffered abuse and homelessness, became a mom in her teens, and raised three boys on her own. O'Bryan, who has experienced homelessness and drug addiction within his nuclear family, has a significant ACE score. But he's at the forefront of changing the conversation and the community.

He's optimistic about the groundwork laid by initiatives like PATF, hoping that "this journey on studying adversity is a pit-stop on the way to a full-out platform of community wellness, resilience [and] health." 

It could be the groundwork that gets the multimillion dollar grant to employ and train people right in the neighborhood, creating jobs and empowering a new field of professionals to foster human resilience across multiple generations. 

In short, O'Bryan insists, "We've got to figure this out." 

This content was created in partnership with the Thomas Scattergood Behavioral Health Foundation, an organization that seeks to create opportunities for productive dialogue and learning within the behavioral health field.
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