PRACTICE & POLICY LECTURE SERIES, APRIL 2014 - ADVERSE CHILDHOOD EXPERIENCES (ACEs): RESPONSIVE PRACTICES IN SERVICE DELIVERY ACROSS MULTIPLE DOMAINS

Dr. Julie Miller-Cribbs: Well, thank you and I'm happy to be here to talk about this topic. This topic has been the subject of research that I've done for a while now in Tulsa. I'm going to talk some about that research and I'm going to talk about some emerging best practices across service domains.

You are going to be... it might feel a little haphazard. It's kind of like that on purpose because I'm going to pick a few things that I think are sort of relevant when you think about ACE-informed practices. Both sort of state systemwide and then sort of at the individual and group level.

So, first I'm going to briefly talk about (inaudible) ACES, why we care about them in Oklahoma and why do we care about them for people who work in public and social services. I'm also going to briefly - because I'm sure that most of you are pretty familiar; so pretty quick - do an overview of ACE study, but then I'm going to talk to you specifically about some Oklahoma ACE data from four different studies based here in Oklahoma that are looking at some different populations. And then I'm going to come back after we talk about that and connect sort of what we're talking about to brain science - again, kind of briefly - and then I'm going to talk about some promising interventions; some systems statewide examples, some individual and group examples that target ACE-impacted populations.

Alright. So, I'm a social worker. Some of you are in the room who are also social workers or psychologists are probably well familiar with the biopsychosocial approach. For a long time, we have understood that our childhood matters, right? That our early experiences shape our adulthood. We haven't fully understood and we are continuing to understand that better and better with the science that we have now. But we've known for a long time that this influences our development across the spectrum, okay? People as early as Freud said it. Now he may be confused and we may understand things differently around brain architecture, explained, you know, these Oedipal things that he talked about. But, you know, we have known for a long time that these experiences matter. Okay.

So, setting the stage - why do we care? Alright? So, I was thinking about this and thinking about this from the perspective of people that work in public services or in social services. Across all kinds of spectrums, right? We're talking about public education. We're talking about healthcare. We're talking about welfare services. We're talking about child welfare. We're talking about juvenile justice, right? All of those people who work in a (inaudible) systems have touched some way and have experienced some way with ACE-affected folks, right? And often times they can be categorized in these sort of different groups. And I've put these in categories just based on the multiple training and conversations I've had and the things I've read. Don't... you know, this is not like published research. These are just my thoughts about it, right? 

Why we would care. Well I would say for one thing that we care is we know that ACE-affected populations are high utilizers of services, right? And often high utilizers (inaudible) necessarily the best kind of income... I mean outcome. Sorry. A lot of income, not the best outcome, right? Okay. 

We also sometimes think of those populations as being noncompliant, right? These are the folks who don't show up on time, don't show up at all, don't come with the paperwork that we've asked them to come with, don't renew their Medicaid or their SNAP benefits on time, you know, often times argue with us, Often times are conflictual in their interaction patterns with us, and often times can sometimes be hostile, okay? And so, we often kind of think of those folks as noncompliant or difficult, right? 

The other kind are what we kind of consider to be like treatment resistant and we talk about that a lot, too. In healthcare we talk about it in terms of people who don't respond to our traditional usual care, healthcare conventions, right? They don't quit smoking when we want them to, they don't lose weight when we want them to, they don't stop using drugs and they don't, you know, they don't follow our instructions, right? We also, in healthcare, see that with (inaudible) that with a relapse, right? And, in child welfare we see that with, just one example would be, the foster care youth that continually blows up their placement over and over and over again, right? And then in education we'll see that with kids with special education needs. Kids that have two or more ACES are something like 70 times more likely to be in special education. That is a really staggering statistic. And then when you think about how expensive special education is compared to regular education, that's a pretty hefty price, okay? Or behavioral issues within schools, right? Teachers would talk about this.

Then we have this other category called the "I'd rather nots." I was trying to think about this name. (laughs) I wish I had it... sort of like "untouchables" or "unwanted" - that didn't sound very good. So Steve Wells, my (inaudible) helped me yesterday come up with the I'd rather nots, right? And these are folks who have conditions or in populations that a lot of us don't want to deal with, right? Folks with borderline personality disorder, right? We hear that all the time, "Oh, I don't want to work with those people." Right? "They are too hard." Right? Or men who batter, or pedophiles, or prisoners, right? These are populations with some of the highest ACE scores of all, right?

If you looked at a survey of folks, and some people have, of folks on death row and you read their qualitative research on them, their stories are abysmal. They are stock full of horrible, adverse childhood events after another. 

And then this is what Dr. Brenner, one of the ACE physician researchers, talks about "the uneasy feeling." These are folks that we work with that we just got that feeling, he says, in the pit of your stomach, you know? They are coming your way (laughs) and you don't want to see them, you know? They (inaudible) nerves, you know... they often fight with you, you don't know what to do with them, you're frustrated, right? 

And so these... they are often in these kind of categories. And so I would hazard a guess that most of us in this room have had experiences with people in most of these kinds of categories and often times these are the kinds of conditions that I'm describing, like I'd rather not, the noncompliant, and the treatment resistant, are sort of the symptoms, right, of the ACE-effected populations. Intersecting, right, with the social welfare or public social welfare services.

So why do we care? It's expensive. It is. And I'm going to show you a couple of slides and we can be done with that. Let's just agree, it's expensive to care longer term for people with adverse childhood experiences. It's very expensive, right? And many of our services and systems are not responsive to the needs of traumatized populations. And sometimes they retraumatize and do more damage than good. The other is that the impact of ACES is very likely to be inter-generational if it doesn't have an interruption, right? If we don't intervene. And the good news, at least I think for a lot of us, is that we have increasingly better science, research and knowledge that can help us better pinpoint where we need to intervene, how we need to intervene; even as technically savvy as CogMed, which I'll talk about in a minute, that it has the capacity to help us re-engineer our brain structures when they've been damaged from ACES in childhood, right? So, we have knowledge, increasing knowledge. Now, I would say it's not always well-organized for us all right yet, you know, because its sort of what I would consider to be an emerging science and when it's not all organized. But is sure is exciting, you know? (laughs) And it sure is helping pinpoint and pave the way for us to think differently about how we might interact with ACE-impacted populations. 

It's expensive, right? If we go down the spectrum and think about institutional care versus when kids - this is child welfare example - when kids get to stay at home, you know, and intervene with them versus thinking through all the ways that they may go through the system, it gets more and more expensive the more restrictive, right? the institutional, the nature of the institution becomes, right? And the most restrictive kinds of institutions which we would all argue (inaudible) right, are the most expensive, right?

And so when we use the numbers of children abused in the U.S. from 2008, someone from the CDC calculated the total lifetime economic burden resulted from that maltreatment and it was estimated at $124 million. That's a lot of money. When you break it down in 2010 dollars and you look at the lifetime cost of one child who was a victim of maltreatment, that's over $210,000. And when you start to go, "Well, what are you talking about, Julie?" (laughs) you know, well break it down, right? What I'm going to show you in a minute, right, is healthcare cost in childhood, adult medical costs, productivity losses from not being able to work due to mental health and health concerns or other disabilities, child welfare costs, criminal justice costs and special education costs.
 
So, most of you are familiar again, I hope, in the room with a study which was conducted over... about several thousand people, and it was the idea of a couple of physicians who said, "You know, we're kind of seeing this connection between what it seems like people are talking about early childhood experiences and their health. And it seems like there might be a connection." So they designed a study and they started to look at what they called Adverse Childhood Events. And those are abuse related items, household dysfunction related items, right, and it pretty much, in most studies where you look at these, you add it up and you get an ACE score of zero to nine, okay? With higher scores representing more adversity in your childhood.

So in the first study, basically they found that just a little under half of the people that they surveyed had no adverse experiences. I want you to remember that number, okay? Because it will matter when I start talking about Oklahoma data, right? So, a little under half had none, right? And about 25% had one, reported one ACE; 13% two; 7% three; and 7% four or more. I want you to remember those numbers too, okay? Because they'll matter when I starting talking to you about Oklahoma. And when you look then at the abuse type and the household dysfunction type, you can see that 22% reported sexual abuse, 11% physical, 11% psychological, and that substance abuse, mental illness, domestic violence, and household number imprisoned, 3%. Remember that number again to you, (laughter) because it's going to matter when we talk about Oklahoma, right? Okay? So, we already knew, before the ACE study, there were a lot of studies that were done and we already knew that about 1/3 of women who were getting addiction treatment had been physically forced to have sex at some point in their life. We already knew that. We didn't know about ACE but we did know that. And we also knew that patients in substance abuse facilities were much more likely to be abused as children. We knew that already also from a body of work that existed. We also knew that a high percentage of women in treatment for mental illness had been sexually abused. We knew that also, right? So we had... we were able to sort of... the ACE study built on that previous body of knowledge that we already had and then started to look... I think what ACE does for us also is sort of look at the cumulative look, right, of multiple ACES over lifespan.

And just think about the fact that we imprison more women than any other state, right? And what that means for a lot of the kids that live in the state of Oklahoma already have one ACE. Essentially, right? And that's an important ACE to have that you're mother or your father is imprisoned.

So, the summary of the major findings in the ACE study and I'm talking about hundreds and hundreds of studies so, you know, let's just take my word for it here and then you can go look it up later... (laughter) is that ACES are pretty common, right? And that ACES are very strong predictors of later health risks and disease. And when we talk about health risks and disease we're talking about health conditions, so things like diabetes, stroke, heart attack and those kinds of things. We're also talking about mental health conditions. Things like depression, anxiety, PTSD. We're also talking about health risk behaviors, right? So things like smoking, eating too much, not exercising. And there's an amazing stair step relationship, right? That you can see on almost every one of those health outcome/health behavior risks and/or mental health outcome. Where the more ACES you have, right, the more likely you are to have those conditions. So whether I'm looking at smoking it goes "zoomp!" Right? If I'm looking at when I started smoking, the age, my age; the age... I'm going to start smoking younger if I have more ACES. I'm going to smoke more cigarettes if I have more ACES. You know, I'm going to quit less often if I have more ACES. Everything that you can think of literally has a stair step relationship with that thing. How many times I eat at a fast food restaurant. (laughs) I mean, it's just incredible, the relationship.

And so, you can see that really clearly in all of the ACE-related research. And so when you start then to look at the conditions, right, that we commonly think about in terms of health risk in our society, and then start to look at the percentages of people within those conditions that have ACES, you can start to get a full picture, right? So within all of these things like alcoholism, or HIV high-risk populations, the number of people that experience ACES within those is significantly high. Alright. 

So, what about in Oklahoma? I'm going to give you a brief overview - and I mean brief, because (laughs) I've reported on each of these studies for an hour so it's going to be quick - but let me just tell you that if you're interested in finding out more, I will be happy to send you more information and talk to you about it. So I'm going to talk to you about four studies kind of briefly. One is a study that we did in the community health clinics in the OU clinics in Tulsa. Three clinics; about 350 people. And the nice thing about this data is we were able to get self-report data on those folks on their ACES but we were also able to link that data to their electronic medical records. So we could look at some more health outcomes that you might not necessarily get that, you know, you won't get with self-report, in other words. 

We also surveyed parents at three of the Educare... all three of the Educare centers in Tulsa. So these are parents of kids in our early childhood program in Tulsa Educare. The cool thing about this study is that we also linked that survey that we did on their ACES and stress and other demographic health access-related variables. We linked that data to Educare-related data on child outcomes that was collected by teachers. Parent interviews they did, child observations that they did. So we were able to kind of link that, our data that we collected on ACES to all of that data. And, believe it or not, in some kind of crazy endevour - I don't know what we were thinking - (laughs) but we decided to collect salivary cortisol in all of the children in Educare also. So, we combined our social science researchy brains with our bio-medical colleagues down the hallway and we (laughs) had some trial and error on even the data collection of how to do this, right? How to get salivary cortisol from a six-month-old baby. Anyway.

And so, I can't answer questions about that data. I'm just going to tell you right now because we are in the middle of analyzing it but we're going to have the potential to look at the parental ACE scores and all this other data combined.

And then on two smaller studies that we've been working on, or that two other people have been working on, in Tulsa are a sample of homeless youth in Youth Services of Tulsa most of them who are receiving services in our Outreach clinic.

And then residents in a public housing facility in Tulsa called Comanche Park, okay? 

Those are the people all involved. I don't want you to think it's just me because that would be crazy. (laughter) There are a lot of people working on this stuff with me. Alright.

So just real quick. This is the clinic sample of ACES. So these are the folks in the OU clinics. Check it out, right? 30% of the folks reported five or more ACES. Remember what I said to you earlier? Remember? What was it...7%? Four or more, national sample? That tells you something right there folks. That's a lot of ACES in our clinic sample. Okay.

In the Educare parents, you can see it's a little bit smaller. The percentage of people who were able (inaudible) longer, healthier sample than the ones in our internal and family medicine and community health clinics. But also, about 30% are reporting two to four and 11%, still higher than the national average, are reporting five or more ACES. Okay? That's a lot of ACES.

When you look at our clinic sample data and talk about stair step relationship, now this is normed on a Z-score so it looks kind of funny, but you can see that relationship there. So, things like heart disease and mental health and substance abuse conditions - the higher the ACE scores get, the more likely they are to have those conditions. That's in our clinic sample. 

And our Educare sample? It's a different way to look at the data but same kind of idea. That the higher their ACES are, the more likely they are to report substance abuse, hypertension, even dermatology problems; skin problems. Okay? And you know there's an emerging research suggesting that cortizol and stress is related to skin conditions like eczema and that's related to asthma and you know, there's this sort of emerging kind of stress-related literature on that. And so we've got, you know, we see that here. We see a rising, we see that there's a relationship with ACE and dermatology, asthma and breathing issues. Arthritis, pain, depression and anxiety.

Depression and PTSD also in our clinic sample. Same kind of relationship. The other thing that we've done, and so far that is kind of exciting for us but sad in terms of what we found in the data, is that we looked at healthcare access and barriers to healthcare in both our Educare and in our clinic sample. And what we found was that ACES were very much related to their experiences of healthcare barriers and their experiences in accessing healthcare services. And so you can see that 41% said that they experienced three to five of the barriers that we listed for them and 23% reported six to eight. That's a lot of healthcare barriers. And those things were things like that saying that, "I needed to get healthcare but I didn't have money so I didn't get it." Or, "I didn't have insurance in the last year." Or, "I don't have it now." Or, "I used the emergency room because I don't have a regular doctor." (inaudible) in the last year (inaudible). 

This was (inaudible) a mind, right? 58% reporting that they have medical debt, okay? And this medical debt question, I'm not reporting on that data here, but I have also found this to be true in two other statewide studies I did for the Oklahoma Insurance Department of young adults, 18-34, who had really high levels of medical debt also and in Soonercare samples of folks who were reporting, you know, significant medical debt. And then unfortunately it's only 7% and in some of the other cities it's been higher, folks who are then going to these payday lenders to help them with medical debt. I can't think of anything worse, right, to try to help you with a medical condition. 

So, when I could combine on some of the variables, both the clinic sample and the Educare sample together, and so just try to look into more of the health conditions when I put this sample together. And again we see the same - that those with higher rates of ACES have reported conditions like arthritis, depression, substance abuse, hypertension at statistically significant levels. And when we look at depression, and this is just some looking at some specific items like reporting, "Were you ever depressed? Have you been depressed for two or more years? Are you always sad?" Again, the higher the ACE score, the more likely they will report feeling (inaudible).

And then, access to healthcare again. Those relationships when we combine the data, are significant. So the higher people's ACE scores are, the more barriers that they experience in accessing healthcare. 

The other thing that was relevant in this study is that we asked them, did they regularly seek care? I'm sorry, did they really receive care as children from a dentist or a doctor when they were a child? And if they have higher ACE scores, they were much likely to report that they did not receive medical care as children. Not surprising, right? I also found that in the Medicaid study. So when we combine them and look at barriers, again you can see those statistically significant relationships emerging. Where there are really big differences between those who have high ACES and those who have barriers to care. 

In the homeless sample, the homeless youth that a colleague, Rick Minnows and Mark Fox are working on in Tulsa, they did something a little bit different. They were surveying ACE in general among that population but they were also interested, they're particularly interested in developing responsive services for homeless youth, especially responsive healthcare services for homeless youth. So they looked at ACES and the relationship between ACES and whether or not those kids trusted healthcare professionals. Other professionals, too, but they were looking at healthcare providers in the medical profession generally. 

And voila, right? The higher their ACE scores were, the more distrustful they are going to be with medical professionals and healthcare professionals. The other really scary thing, and remember I said, "Remember that number"? Oh, my little red circle is wrong, right? But 72% of that population reported that they had four or more ACE scores. When you have four ACE scores, that's when you start to see really significant impairments in health and mental health, so that's an alarming number of folks. Now it doesn't surprise me because a lot of the kids who were served by this agency and who were homeless in this area, and probably it's true nationally, are emerging from foster care, right, and have run away because they have abusive homes. So it shouldn't surprise us that it's a higher than national average but quite frankly that number is really high for me.

So if I'm thinking about Oklahoma, I'm thinking, "Wow," right? That we have, you know, and granted it's not a statewide survey, but we've got a lot of folks, right who are experiencing high levels of trauma and they are entering our services of care. And I would venture to guess, if we're seeing that in our health clinics and we're seeing that at the Educare settings, we're going see if I look at, for example, welfare recipients or (inaudible) folks who are receiving our public services. And in fact, in a lot of other states when they have surveyed, for example, people on TANF in the state of Wisconsin, I think is one of the studies, they have found that very thing, right? That those folks who were receiving TANF have higher ACE scores. Okay.

In the Comanche Park, I don't have a slide on it, but in the Comanche Park study, they are actually doing a community survey because they're developing a community health peer support program there and they were trying to look at ACES within that population and trust and they found the same thing also in the public housing project that the higher the ACE scores then that was related to the trust of medical professionals.

So, quick summary of (inaudible) right? We have a high level of (inaudible) early childhood homeless youth in public housing samples. Alarmingly high, okay? They're related to their health and their mental health and their health risk behaviors. They're related to their access to healthcare and the barriers they experience accessing those healthcare. And also, it's related to their trust of professionals that are really there designed to help them. And those adults with ACE scores are much less likely to have gone to a dentist or a doctor when they were younger, right? And likely setting the stage for lower access to healthcare as adults and certainly not setting the stage for regular preventative care, right? But more what we would consider to be high-end, high utilizer care in adulthood, okay?
 
And so this sort of pattern emerges with the data: the higher the ACES, the more barriers, the less trust of medical professionals, you know, the more health care problems and risks associated with those ACES, okay? And so, I think our Oklahoma data validates some of the national findings. I think it paints a pretty kind of scary picture for us in Oklahoma, thinking about what the levels of trauma may be in our state. Which, you know, given the rates of poverty and given the rates of women in prison, and other things it's not too shocking but it still means that we need to be thinking about, what are our responsive policies for working with ACE-impacted populations in our state? 

So tying it all back together from ACE to adulthood, right? So, I just told you briefly about the ACE study, right? And then I walked you through some data related to some national findings and some state findings, okay? So, one of the questions I had when I first learned about this is, "Okay, but what the heck is going on? How do we understand what is happening from here to here, right? What's going on?" Here's where it gets kind of helpful for us with emerging science, right? Because now we have some good understanding of some of the core concepts of science of early childhood development that helps us understand, right, what might be happening from here to here. And again, that knowledge helps us understand how we might better intervene, okay? 

So, I'm going to run through these (laughs) very quickly. Because I'm going to assume also that a lot of you are pretty familiar with some of this stuff. But, we already know that one of the core concepts is child development is critical for a good society, (laughs) you know, and community development and economic development. We need to have a healthy, well-educated population for economic prosperity, you know, for our communities to work the way we want them to. 

We also really know that the experiences that we have as children... Actually, the experiences - let me correct myself - that we have pre-conception, and even in-utero, shaped our brain architecture by the overproduction of connections. We call it neural proliferation, right? And that those things get pruned. And that's normal and healthy and part of our brain development. But in conditions of toxic stress, right, that pruning doesn't work the way we want it to. We also know that brains build from the bottom up, skill by skill. Simple to more complex things, right? And this is an important concept which I'll talk about in a minute, because sometimes we haven't always thought about how skill begets skill. Why it's important that we learn, as babies, we learn language first, you know. And then eventually we develop cognitive skills. Other higher cognitive skills. And that our genes and our experiences together build our brains and the importance of serve and return relationships. And that our cognitive and our emotional and our social development are all linked together, right? And so therefore, our mental health, our physical health and our behavior are all related. And sometimes we've separated those things, you know, because we think about interventions in the cognitive or, you know, in the emotional but really they are very connected.

We also know that toxic shock... I'm sorry. Toxic shock? (laughs) Same thing, maybe. Toxic stress damages brain architecture, okay? 

And for many functions, the brain's capacity for change decreases over time, right? And so this is one of the more important... this is why we emphasize early childhood development so much. Because we know that our brain architecture changes and some of those things make it harder to change. It doesn't mean that they can't change. Because some people say that, "Well, you know, I can't change." Yes, you can, right? It's just that the neuro-effort (laughs) to change becomes a lot more difficult as we get older. 

Okay, so again, our brain goes super-fast in the first three years. 700 new synapses or neural connections are formed every second, right? That's amazing, I think, right? And pruning is where our synapses are reduced to make our brain circuits more efficient, right? So, at birth they're firing away like crazy, right? And then they continue until about our teens and then they start to decrease a little bit. This is why babies stick things in their mouth, right? Because they learn from all of these avenues, you know, they're sticking things in their mouth because they have got all these things on their tongue which helps them understand them. Because you know, we don't need to stick things in our mouths as adults because we already know what that feels like, right? We've already stuck something in our mouth... (laughter) And our things have already pruned and we've figured out, you know, that we don't have to do it anymore, right? And so, it helps us understand, I think ,in fact why, you know, why babies do the things they do. You know, when we start to understand these sort of developmental things, okay? 

And it's sort of use it or lose it thing. Right? These early experiences impact the nature and quality of the brain architecture as it's developing by determined what circuits are going to be reinforced and what ones are going to be pruned, right? So if they're positive ones that are getting pruned, then you know the circuitry that's developing is healthy. If they're negative ones, like their fear of flight or I'm under stress, right? Then I might be developing not the best circuitry to respond to my environment. I might be fighting all the time, right? Or I might be hiding all the time because of the way that my circuits are because I've been, you know, developing under stress. Okay.

And these connections continue and prune in order, right? The brain's not a blank slate, right? So what I was talking about a minute ago was these sensory pathways happen first: vision, hearing. Then language and then these higher cognitive functions, right? As our brain develops over time. Okay.

And then serve and return - developing confidence, right? Brains are like sponges. We always say, "Oh, kids are like little sponges." That's true, they are. They soak stuff up. But if you think about it, what they really are like, "Why? Why? Why?" 

(laughter)

Dr. Miller-Cribbs (continues): "Come here. What's this, what's this, what's this?" you know, whatever. And what do we do? "That's a cow" or "Because that's the way the moon shines" or "Mommy said so." Or whatever we are trying to, you know, whatever we can manage at the moment. But that's a serve and return relationship, right? I'm crying, I'm getting picked up, right? And they grow through those experiences and that's when the brain develops. And the confidence that they develop is through the serve and return or the interactive relationships that their genes and their environment. I mean if you... I play tennis and I was thinking about this. And if I serve, right, and nobody is ever there, I'm just going to stand there and serve, right? And eventually I'm going to get bored, and I'm going to leave, right? Well, put that in a context of a baby, right, who's serving by crying or by asking for something. And in the case of neglect, right, and in extreme neglect, they just shut off. We call that failure to thrive, right? Because they are serving and no one's returning. So take that from a context of maybe not quite failure to thrive but in the case of depressed mothers, right? Or substance abuse but the substance abusing parents and the service (inaudible) turn off.

There's this great video, it's only two minutes on the ACE connection's webpage that shows a baby in a seat. 
It's actually, for those of you who are sensitive, you might not want to watch it. It's a research study where they have babies in a chair and the mommy is going, "Hey, hey, hey," talking to them really nicely for about two minutes, you know, or one minute even. And the baby is all like, "Ha ha," pointing, you know, and then reacting. And then all of a sudden, the mom stops and she just sits there. She just sits there. She has no expression on her face at all. She has what we call a blank face, a blank stare kind of thing, right? And the baby freaked out. I mean, eventually... she tries. She's like, "ah, ah, ah, ah!" She's waving her arms, right? She looks distressed and she turns around and she's like trying to get it and eventually she cries. She gets distressed, right? Because her serve and return is off, right? 

And the development of cognitive, social, emotional skills are all connected. And our wellbeing and social confidence are dependent on that, right? They provide the foundation for our cognitive abilities, right? They manage our cognitive processes or our executive functioning, okay? 

This is an important concept because the good news too is that there are some good interventions out there like CogMed and other things for improving executive functioning, right? Executive functioning is important because it helps us with things like working memory, reasoning flexibility and problem-solving. Somebody in the toxic stress environment, right, doesn't always have the best executive functioning skills. So, go back to what I talked about early on about noncompliance. It makes sense to me that somebody under toxic stress would forget their paperwork, would miss their appointments. We already know that neuro-biologically their executive functioning is off. We should almost expect them to behave the way that they do because that is, in fact, what's going on in their brains, right?

It happens to us already, right? You know, anybody in the most... the classic example is you're real stressed out. What do you do? You lose your keys, you know, whatever. This morning, you know, I was a little bit nervous because my GPS wasn't picking up the name of this street because I guess it's a new street (laughs) so I was like, "gosh." And I'm not from Oklahoma City so I was a little anxious, whatever. So I go to a Starbucks, which I go to all the time, right? So it's actually a muscle memory. I would say... me going to Starbucks...

(laughter)

Dr. Miller-Cribbs (continues): And I literally, and I'm not joking you, I literally drove right past the place where you order the drink and went right up to the window. 

(laughter)

You know, and I'm a person, right, who, you know, doesn't have a lot of ACES, you know, who's pretty healthy. The funny thing is about that experience is I can take that experience and laugh about it. And I can say to myself, "Oh, you're kind of stressed. Which is why you did that, you goofball." I don't internalize that as a part of who I am, right? But if I grew up in a toxic environment, right, I start to integrate that. "I did that because I'm an idiot," you know? "I did that because I never do anything right," right? And so, I haven't figured out how to develop confidence and confidence in myself because all of my experiences pretty much have been adverse. My serve and return has been off, right? 

So, instead of... when I do something my mom always said, "Great job Julie!" You know, even if it was the worst drawing on the planet, right? You know, I got positively reinforced for the things that I tried, right?

Another example I give is my daughter. When she was really little she was trying to learn how to do those little things, like tires, and you just, you know, I don't know, she was just really excited about learning how to do it. And my husband and I were standing there I heard her go, "You can do it, Kawie." (laughs) You know? And it was her own little internal narrative (inaudible) about her developing confidence which she got from us, you know?

And so, that is how we, you know, when you don't have that foundation, that executive functioning foundation, those things are off. And then you develop problematic narratives right, about yourself, depressogenic schemas and other things, right, that make it difficult for you to function. 

And so, toxic stress damages brain architecture and has very long-lasting impacts that are difficult to recoup from. So, we have mostly experienced positive stress. I explained that today at Starbucks. And being up here, you know, I'm sure if we measured my cortisol it would be higher than normal. And my heart rate is probably a little bit higher than normal, right? But it's a positive stress because it's helping me get through this talk and giving me the energy and adrenaline I need to get it done, right? And I'll be fine. I'll recover. And then there's other things where there's tolerable kinds of stress that are serious. Like if a parent dies. But if there are supportive relationships in place and people can kind of, then kids can recover from those. It's the toxic, prolonged activation of stress response systems and the absence of positive relationships that cause that longer term toxic stress (inaudible) damaging effects to the brain, okay?

So, when we don't have a lot of stimulations for serve and return, we have different, you know, we have problems with language (inaudible) and we have too much stimulation, like in the form of stress, then we have problems with the development of architecture of the brain.

If you just look at all kinds of research like this like (inaudible) word, (inaudible) here versus, you know, the number of books that are in the household and all those kinds of stuff where we talk about (inaudible) that shows us really clearly that's an important piece. We also have this really kind of exciting way now of looking at neurology, right, the (inaudible) connection (inaudible) image by toxic stress, it has fewer connections. We can actually see it. We can see the impact of stress on our neurons. When we think about where we're supposed (inaudible), you know we talk about static load; that's sort of this idea that, you know, we can (inaudible) then we kind of keep. We have a (inaudible) response to it but then we can get back to normal, right? We can kind of balance ourselves out. But when we have stress events, right? It makes it more difficult. So this... when our stress system has a regular hit, we cope. We get back to normal, right? That's our normal pattern. But when someone is experiencing prolonged stress, they get up here, right? And it's hard to recover from that.

Last but not least, it's sort of this pay now or pay later concept, right? Change gets harder and more expensive the older that you get, right? Ice skating or skiing is a great example, right? If you teach little kids how to ice skate or ski, you know, they're like zoom, zoom, zoom, zoom! You've seen them, right? Right? You can learn to ski at 21 or, you know, 35 or even 40, or even 50. It just requires a whole lot more physiological effort required to enhance those neural connections to get you to learn how to do it. It's the same with language. It's why little kids are so much better at learning other languages faster than adults. 

Okay. So, how do we help? The National Child Traumatic Stress Network has a definition, I'm not going to read the whole thing to you, but I wanted to talk about one of the things that seems to be present in all of the models out there for what you would call a system-wide response to trauma and stress. Which is that the knowledge... sorry, the programs and the services within such a system really infuse and sustain trauma awareness throughout all aspects of the system, right? From cultures, practices, (inaudible) that it has to be written to the way that we do work, right? And that the work is done in collaboration with those people that are receiving the services. 

And this a list of things, I'm not going to read, but the two things in blue that I wanted to point out and one is that we routinely screen for it, right? And ask for it. I ask about it. We've been talking about this a lot. Some of the controversy is, "Well, I don't want to ask for it. I don't know what to do when I ask them about it." Well, you know what? It doesn't mean you have to be there to solve it. You can have an empathetic, caring response and just say something like, "It sounds like you had a really hard childhood. That might be related to how you're feeling today. That might be related to your health, or your mental health. Have you ever thought about that?" You don't have to solve childhood sexual abuse in one encounter. But you can be empathetic in your response and help people make those connections, right?

And so, there's a, I think the myth that, "Oh, if we screen, we have to have this complex array of services for people." Not quite right, you know, I mean we do. We need to have responsive services but I think there's a lot just by asking and showing empathy. Even just as a minimal level kind of intervention.

And the second thing I wanted to point out here is maintaining environment for care for staff. And I'm going to talk about that in another slide in a second. But that's a real issue. Because it's hard to work with these populations. There's secondary trauma and there's stress. And there's a fine line between a lot of our frontline workers and the clients. Often times surveys of our frontline workers experience just about as many ACES as the folks we're trying to serve.

SAMSHA has another definition - very similar - but they talk, too, about the thing in red which I think is an important point when you are looking at these models about trauma-informed care about making sure that your traditional service delivery mechanisms don't exacerbate trauma. Because sometimes they do. The rules and regs and policies and setting up offices so that they don't feel very friendly. They feel off-putting. You know, we put glass over the windows. There's nobody for them to really talk to. They're kind of sterile. All these kinds of things are kind of scary. Even more scary and may actually exacerbate to people with trauma.

So there's a ton of great resources out there for you. Which is a great thing about developing models for trauma-informed system of care and all of the domains. So no matter who you are sitting in this chair, there ought to be one for you on this list. And they're organized real (inaudible) disconnect (inaudible) pages and they include tutorials, assessment tools, you know, videos. I mean, all kinds of tools that agencies can use or systems can use within these different domains.

The other thing is public campaigns and education. I would probably argue that it's probably time for Oklahoma to start thinking about this, you know? I mean, we have a high level of people experiencing ACES and it's a health problem. It's an epidemic, really. And it's contributing to significant problems in our state, right? So, other places, other states have been starting to do this and thinking about it. It's important, right? Other kinds of national campaigns have really good beneficial things. Think about the campaign for awareness, about mental illness, right? Or about domestic violence for example. Those kinds of things reduce stigma. They give people a common language. They sensitize people to the issue, they reduce isolation of people who experience those events, they heighten awareness. You know, they give us a common language and understanding. These things are not that hard to do and we've already seen them. If you drive around Oklahoma now, you have all these smoking campaigns, right? You can do something similar with ACES. 

And actually the CDC has a really nice... it's actually this, it's kind of long but it folds up into a nice brochure and you can order them or you could print them on your computer or whatever and have them in your office or whatever you want to do with them. That is really what I would consider to be sort of a common language explanation of ACES in a kind of a public campaign. And I'm not going to, you know, I'm just going to put it up there so you can see it but basically has these five sort of categories. It's like, What are ACES? (inaudible) pretty simple. How common are they? Right? How do they affect our lives, sort of a nice graphic, kind of shows you sort of, okay, if you have an ACE score of one then, you know, you kind of have this many dots of these conditions; ACE two you have kind of this many dots and the dots get bigger, right? So it's kind of a nice way to explain it. How do they affect our society? Life expectancy? And economic toll. And then sort of a brief like, what can you do, right? Just an example of one kind of campaign.

Another thing is to screen and measure and count, right? I know I'm a researcher but it's hard to know if you're impacting change if you don't know what you have, right? And so , we have in some sense of what we have in Oklahoma. We won't have a clear picture, right? So we need to know, I think on some level, what is going on in our state state-wide and our services and so we need more studies and screening of it, of ACES.

Several states are already doing statewide surveys. They're using that brief, the module of the brief risk factor surveillance system to collect data so they report on ACES in their adult population. And some of the Kids Count and the Casey Foundation people have been talking about including kids' exposures to ACES in their Kids Count kind of data. I think those are good initiatives because they help us know what we're dealing with and then we have data to which to know if we're making a difference or if it's getting better or worse. 

And then statewide initiatives and programs. Like in Washington State and Iowa. In Vermont, interestingly enough, a physician just suggested a bill that would require screening for ACES in all healthcare settings in the state of Vermont and require ACE-related curriculum in all medical and healthcare education and continuing education in the state of Vermont, you know, as an example. 

So the other thing is frontline workers, right? Reception, triage, ER folks, and case workers. People who are on the front line every day. Often people who also have high ACE scores themselves, right? So we have to be able to... if we want to have a responsive system, we've got to train those folks. We do reasonably good job often with continuing ed for training nurses, social workers, physicians, other kinds of people in the setting. We often ignore our frontline staff. And often times they are the first line of defense, right, for dealing with folks. They are the people who often can be, that make the difference between someone leaves or stays and access services. And, so we have to train them, sensitize them, reduce isolation and heighten awareness for them also, so that they can better respond and have better skills for, you know, how to deal with a hostile client. Or with someone (inaudible). 

Early childhood programs, it goes without saying, I think. We know that from early (inaudible) and early childhood programs plus with programs that support families, economic development (inaudible).

I'll skip that, I'll come back to that in a minute if somebody asks me.

Okay, and then, I know I'm running short. I'll try to fit it, I'll wrap up. (laughs) 

In the classic sort of ACE triangle that you've all seen, you know, where these adverse childhood experience lead to impaired neurofunctioning, impaired social, cognitive and problematic behaviors. When you think about it, most of our programs rest the observable behaviors that stem for ACES sort of the top of that pyramid. And so, what we're seeing, I think and what we know from neuro-sciences we could be thinking about interventions here. Some of those are what I consider to be preparatory interventions. Or interventions that might help people better respond to health behavioral interventions. Or parenting classes. Or, you know, whatever else, you know, what you think, or education, for example. But we don't do that. We sort of assume that they are all kind of sitting there at the right page ready to have the intervention and we know that's not.

Stress (inaudible) to have experienced trauma in the past may not (inaudible) response to traditional interventions. So we want to expand the focus, right, a little bit. So there's four categories of things that I just wanted to mention today and then I'll be done, I promise. (laughs) The first is meditation. The second is executive functioning and training. The third is attachment-based interventions and the fourth is modifying our health behavior interventions using things like mindfulness-based CBT or mindfulness-based stress reduction.

Interestingly, many of these have wide application for trauma and non-trauma affected folks. If they can be positive for everybody. Meditation you may be thinking (inaudible) maybe not. For some of you in the room (inaudible). There is research out there paid for and supported by the NIH, the American Medical Association, Psychological Association, that shows that transcendental meditation and mindfulness meditation have amazing impacts on just all kinds of educational outcomes, anxiety relief, reducing cortisol, reducing blood pressure, heart attacks because why? They target the underlying stress and anxiety and imbalance with, that we talk about when we talk about what's going on with ACE-impacted populations and increase alertness, integration and calm. So they can help prepare for interventions but they can also then be used alongside or plus with other interventions. Tell.

And so there's all kinds of research (inaudible) that's really helping the (inaudible) level (inaudible) health, mental health outcomes at the group level. There's a whole bunch of schools out there now that they might call, they're called toxic schools. Where they have a whole bunch of kids that've experience a lot of ACES. You know, there's a lot of disruptive behavior. And they've found great outcomes when they stop the day, twice a day, and have every kid use mindfulness or transcendental meditation for ten minutes, twice a day. They have reduced behavioral problems, they have better academic outcomes, they're seeing all sorts of (inaudible) so from meditation. Crazy, right? But in the interviews that they do with the kids, they articulate it really well. They'll say things like, "I know my friends think I'm crazy, but I feel so much better when I do it. And all that stuff going that I'm reading about (inaudible)." So it sounds cool, right? That's what I'm talking about. Preparatory intervention, right? Gets me ready.

And then military is doing a lot of it with PTSD, both groups and in individual and we can teach it across the board. 

CogMed is an easy, executive function, computer-based tool that's been shown to increase executive functioning. We can all do it. It will help all of us. But it helps trauma-impacted populations, in particular. But they use it with stroke and other kinds, you know... aging population, to help improve concentration and memory and other things. But the stress associated with toxic stress means your working memory and your executive functioning doesn't always work. And so you can actually re-train your brain to do those things better. Okay. 

And then, poor attachment and regulation we know, right, in child welfare world - so when we think about programs like PCIT, right, as one of those kinds of programs that deals with this for like kind of pre-triangle, another very promising intervention. 

And then for health behavior intervention same kind of thing, right? Imagine going to your doctor and they say, "quit smoking", right? Or like, my doctor saying, "You know Julie, your blood pressure is pretty good but you probably ought to exercise a little more and lose a little weight." And I'm like, "I'm playing tennis! (laughs) Maybe I shouldn't eat so many salty Doritos. Okay? Fine." You know, I don't even have high ACE score and I find health behavioral change hard, right? So imagine it with a high ACE score and I go to the doctor and they say, "You're going to die if you don't quit smoking" or, you know, "You're going to..." you know, they do. They do sometimes say those kinds of things. Or, you know, "You're going to die if you don't quit eating", right? And I'm a product of toxic stress? You want me to do what? You know? I'm not going to quit smoking or eating. That's a really important coping mechanism for me. And I don't handle distress tolerance very well. And I sure am not going to handle nicotine withdrawal very well, right? If I've got distress intolerance, which a lot of ACE-impacted people do. 

So, traditional healthcare interventions aren't going to work very well. They're going to have to have preparatory, sort of, relaxation, mindfulness, space CBT kind of techniques associated with them if they're going to work. So that people get ready to do the other things.

So, when we think about expanding the focus of the intervention, we think about dropping down to that ACE triangle and what we know about brain development. And then we can start pinpointing better and I think we're going to get more and more and we're going to know more and more about how we can think about these innovative ways to help people who are ACE-impacted. 

So, that's it.

(applause)