Embedding Prevention of Adverse Childhood Experiences (ACEs) into Policy and Programs

Friday, November 22nd, 2019
Victoria, British Columbia

The Canadian Institutes of Health Research (CIHR) in collaboration with The British Columbia Ministries of Health, Mental Health & Addictions, and Children & Family Development; Public Health Agency of Canada (Regional Operations-Western); Michael Smith Foundation for Health Research; Public Health Association of BC; and Doctors of BC.

Objectives

The Best Brains Exchange (BBE) brought together key health system stakeholders including: local and international health professionals, practitioners, policy advisors and researchers to collaboratively support initiatives that will strengthen provincial policy approaches that specifically address Adverse Childhood Experiences (ACEs) and build resilience among communities in British Columbia (BC).

More specifically, the BBE allowed participants to:

  1. Gain a more thorough understanding of current research evidence on ACEs, including:
    1. Limitations and gaps in existing research;
    2. Context and culture as pillars of research and its application;
    3. The application of research into policy-making practices.
  2. Examine innovative ACE prevention and reduction interventions that have been implemented, including best practices and lessons learned focusing on:
    1. Community-based capacity building initiatives;
    2. Culturally sensitive approaches/models of care;
    3. Scalability of interventions.
  3. Lay the foundation for a Framework for Action to prevent and address the impact of early childhood trauma on health, social and economic wellbeing in communities across BC. This should build on existing, related provincial strategies and reports, such as BC’s Guiding Framework for Public Health [ PDF (5.8 MB) - external link ] and the Ministry of Mental Health and Addictions newly released strategy A Pathway to Hope: A roadmap for making mental health and addictions care better for people in British Columbia [ PDF (1.1 MB) - external link ].
  4. Build meaningful relationships among key health system stakeholders to support the collective adoption of a future Framework which enables integrated action moving forward to address the negative impacts of ACEs across BC.

Background and Policy Context

Since the publication of the California-based Adverse Childhood Experiences (ACEs) study in 1998, there has been a growing body of research related to traumatic experiences in childhood and their impact on lifelong health. The initial phase of the ACE Study was conducted from 1995 to 1997 and included more than 17,000 participants.  This study is one of the largest investigations conducted, linking traumatic events in childhood to long-term health and social consequences.

The evidence within the study clearly indicates that those who have experienced maltreatment during childhood are at greater risk of developing earlier and more severe mental health and substance use issues; have an increased likelihood of comorbid chronic conditions; and have poorer responses to treatment. Globally, the World Health Organization considers ACEs a public health problem based on widespread prevalence estimates, the interrelated and intergenerational nature of ACEs, and ACEs cumulative effects on multiple domains of health and social wellbeing.

There continues to be growing interest in BC and other Canadian jurisdictions to consider ACEs in the development of health care delivery models and approaches. Some organizations are implementing “trauma-informed” approaches, while others, including maternity clinics, are testing the ACEs questionnaire for appropriateness in perinatal care settings.

In October 2018, a provincial working group was formed to discuss how ACEs could inform policy and practice; stemming from two Doctors of BC-organized ACE summits (November 2017 and May 2019). Prior to the formation of the working group, previous discussions focused on screening and the administration of the ACEs questionnaire; which some partners considered a deficit-based approach to care. More recently, working group members have committed to focusing on preventing adverse childhood experiences, promoting resilience, and offsetting the intergenerational effects of ACEs through implementation of evidence-based practices.

Additionally, the BC Ministry of Health is preparing to launch primary care networks for the province. The Ministry of Mental Health & Addictions has recently released a provincial strategy focused on prevention, early intervention, children and youth, and Indigenous health and wellness. BC’s Budget 2019 emphasizes the importance of improving mental health care for children and families, with a $74 million investment in child and youth mental health, including funding for community-based childhood social and emotional development programs. It is an opportune time to highlight successful prevention research, community capacity building initiatives, and care models to inform these Ministry agenda items.

Need for Evidence

The BC Ministry of Health considers trauma-informed approaches to ACEs as system-wide and distinct from trauma-specific treatments and interventions. In this spirit, leaders from across the social sectors came together at the Child and Youth Mental Health and Substance Use Collaborative 2017 ACEs Summit to develop a consensus statement which demonstrated the government-wide commitment, having identified cross-cutting priority areas including the need to enact proven interventions to address ACEs in education, health care, social services, justice and poverty reduction.

The BBE brought together key cross-sectoral and regional stakeholders to learn from internationally recognized experts leading ACEs primary prevention research and programming implementation. More specifically, experts showcased successful models for promoting positive mental health development, community-based capacity building initiatives that are culturally safe, and how to work towards preventing adverse childhood experiences altogether through exploring social policy frameworks and the significant impacts of the social determinants of health. This evidence will allow both governmental and non-government stakeholders to gain a better understanding of resiliency and the interruption of trauma to promote positive health outcomes and help inform the development or enhancement of local programs and policies.

The discussions at the BBE, research evidence and, lessons learned and best practices from jurisdictions will help to inform a BC-specific approach and pave the way for action in addressing ACEs. This requires convening researchers, policy makers, and health system professionals from across the province to discuss necessary regional adaptations or considerations, including embedding cultural safety and humility across the provincial system. As well, an innovative, evidence-informed approach is critical to address ACEs in the context of their root causes – the social factors that impact individuals and communities including racism, loss of culture, poverty, social exclusion, gender-based violence and lack of access to education and employment.

Anticipated Outcomes

Hosting a BBE provided an opportunity to hear from, and network with, key international researchers and policy makers, allowing us to: gain a more thorough understanding of current research evidence on ACEs; examine innovative ACE prevention and reduction interventions; lay the foundation for a Framework for Action; and build meaning full relationships over the long-term. Increasing our understanding and fostering a broader community of practice allows us to build a more resilient trauma-informed system of care – one which promotes both, positive mental health and strives to offset the intergenerational effects of trauma.

With the information gathered and connections fostered through the BBE, it is anticipated that key stakeholders will continue to meet as a working group to promote systems and policy change to prevent ACEs, build resilience, and offset intergenerational impacts of trauma across all relevant sectors. Moreover, this BBE comes at an opportune time; with the release of the Province’s new mental health and addiction strategy comes a public commitment by the BC government to prioritize proactive approaches focused on early intervention and building resiliency in people and communities.

Presentation Summaries

The BBE was facilitated by Michelle L. Gagnon, President and CEO of the Palix Foundation and Alberta Family Wellness Initiative & Adjunct Assistant Professor, Cumming School of Medicine, University of Calgary & Member of the Institute Advisory Board on Health Promotion, CIHR.

Here is a summary of the evidence presented by each of the presenters:

Understanding How Experience Shapes Human Development Can Improve Policy & Practice

Laura Porter, Co-Founder, ACE Interface

We live in a time when scientific discoveries and ancient wisdom about the healing power of community and the effects of experience on seven generations are coming together to inform more powerful strategies for improving population health. An epidemiological study with over 17,000 participants called The Adverse Childhood Experience Study found that ten categories of childhood adversity are common, interrelated, and have a cumulative effect on population wellbeing. International ACE Studies now reveal the same pattern: population exposure to the biology of adversity/trauma during development has a strong graded relationship to health risks, chronic disease, social problems, and co-morbidity. Since the time of The ACE Study, scientists in the fields of neurobiology and epigenetics have documented the reasons that ACEs are the most powerful determinant of the public’s health. Experience causes adaptation of the brain and body during development, which creates strengths and challenges that can interact with social expectations to cause progression of adversity across the life course. Developmental adversity reliably predicts the rates of many costly problems, yet our public systems are structured to address each of these problems separately. Positive experience and parental supports in the context of resilient communities can reduce risk and disease for this and future generations. ACEs are a common cause of a large portion population risk behavior, chronic disease, leading causes of death and disability, social problems, and co-morbidity. Understanding NEAR Science (Neurobiology, Epigenetics, ACE, & Resilient communities) can inform policy and practice and thereby improve the rates of many problems concurrently.

Addressing and Preventing Community-Level Trauma: A Framework for Community Resilience and Healing

Howard Pinderhughes, Professor, Department of Social and Behavioral Sciences, School of Nursing University of California, San Francisco

The Adverse Community Experiences and Resilience (ACE/R) framework is a ground breaking framework that defines community trauma and identifies the impacts of interpersonal, community and structural violence on the physical, emotional, mental and spiritual health of children, youth, families and communities. Dr. Howard Pinderhughes described how the ACE/R framework is being used in over 20 cities around the United States to heal communities from the effects of Adverse Community Experiences and restore communities to their role as the fabric and foundation of resiliency for children, youth, adults and families.

Buffalo Journey: Seeking and Asserting Métis-Cree Knowledge and Practice to Child, Family and Community Growth and Empowerment

Janet Smylie, Professor, Dalla Lana School of Public Health, University of Toronto & Director, Well Living House

At this time of Truth and Reconciliation, there is an expanded openness on the part of many non-Indigenous policy makers, academics, and service providers towards Indigenous models of health and social services.  This presentation highlighted some key Indigenous community requirements and strategies for the successful and respectful advancement of Indigenous child and family health programming. Common pitfalls, examples, and recommended actions will be discussed.

Self-Healing Communities: Family-Community-Province Partnerships That Generate Wellbeing & Reduce Costs

Laura Porter, Co-Founder, ACE Interface

Costly health and social problems are complex, and occur in a place: families, neighborhoods, community.  These contexts for health and wellbeing are powerful focal points for generating improvements to population health, safety and productivity.  To accomplish this in Washington State, USA, we structured family, community, state partnerships differently – focusing on learning, and building community capacity to solve complex problems. A natural experiment due to a state revenue shortfall provided opportunity to compare communities using, and not using, four distinct and cyclic phases of community-centered work while adhering to six principles.  We found that communities using this process- and principle-centered model reduced the rates of five or more major social and health problems concurrently and produced both biennial and long-term savings in public entitlement programs.  Rates of Adverse Childhood Experience in the young people coming into adulthood in these communities were lower than in the communities not using the Self-Healing Communities Model. Family-Community-Province partnerships can be structured to shift the trajectory of population wellbeing.

Building Community Resilience: Collaborating Across Sectors to Promote Healing, Foster Equity and Build Resilience

Wendy Ellis, Director, Building Community Resilience, Milken Institute School of Public Health, George Washington University

Across the U.S. coalitions made up of grassroots organizations, public health, health care, social work, education, governmental agencies and other sectors have used the Building Community Resilience (BCR) process to address inequities that result in adverse childhood experiences and adverse community environments (the Pair of ACEs). Using the BCR process, community and organizational leaders, leverage data and resources to address the economic, social and environmental factors that contribute to a community’s resilience through trauma-informed practice and policy change. Project Director, Dr. Wendy Ellis discussed the science, historical and political context that informs these multi-sector initiatives and shared lessons learned from this ground-breaking work.

It’s Like A Jungle, Sometimes It Makes Me Wonder: Growing Up and Watching My Community Get Traumatized

Howard Pinderhughes, Professor, Department of Social and Behavioral Sciences, School of Nursing University of California, San Francisco

Dr. Howard Pinderhughes chronicled his and his community’s experiences growing up which resulted in Roxbury becoming ground zero for Boston’s emergence as the youth murder capital of the United States in the early 1990’s. These experiences formed the basis for the formulation of the Adverse Community Experiences and Resiliency Framework (ACE/R) which has helped transform approaches to trauma prevention and health promotion in communities around the United States.

Recommended Readings

  1. Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C. H., Perry, B. D., ... & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. European archives of psychiatry and clinical neuroscience, 256(3), 174-186.
  2. Building Community Resilience Tools & Resources. (2019). Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, George Washington University. 
  3. Building Community Resilience Two-Page Summary. (2019). Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, George Washington University. 
  4. McEwen, C. A., & Gregerson, S. F. (2019). A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years. American journal of preventive medicine, 56(6), 790-794.
  5. Porter, L., Martin, K., & Anda, R. (2016). Self-healing communities: A transformational process model for improving intergenerational health. Princeton, NJ: Robert Wood Johnson Foundation.
  6. The Community Resilience Model. (2019). Building Community Resilience, Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, George Washington University.

Online References

  1. Ellis, W. R., & Dietz, W. H. (2017). A new framework for addressing adverse childhood and community experiences: The building community resilience model. Academic pediatrics, 17(7), S86-S93.
  2. Pinderhughes, H., Davis, R., & Williams, M. (2015). Adverse community experiences and resilience: A framework for addressing and preventing community trauma.
  3. Smylie, J., Kirst, M., McShane, K., Firestone, M., Wolfe, S., & O'Campo, P. (2016). Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review. Social Science & Medicine, 150, 128-143.
  4. The Government of British Columbia. (2019). A Pathway to Hope: A roadmap for making mental health and addictions care better for people in British Columbia [ PDF (1.1 MB) - external link ].
  5. The Government of British Columbia. (2019). TogetherBC, British Columbia’s first poverty reduction strategy [ PDF (882 KB) - external link ].
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