Protecting Our Children: COVID-19's Impact on Early Childhood and ACEs

Kathryn Santoro (00:00:00): Thank you. Hello, I'm Kathryn Santoro, director of programming at the National Institute for Healthcare Management Foundation. On behalf of NIHCM foundation we want to extend our sincerest thanks to the healthcare and essential workers on the front lines of the COVID-19 pandemic for continuing to keep us safe. Our goal today is to share information and guidance on early childhood development, adverse childhood experiences and the COVID-19 pandemic's impact on children, along with actionable strategies and resources.

Kathryn Santoro (00:00:37): In an infographic NIHCM released last week, we highlight the impact early adversity has on lifelong health. Prior to the pandemic, one in six children lived in poverty. The COVID-19 pandemic has highlighted the longstanding inequities that affect the lives of children and families. Experiencing adversity such as economic and social equities, abuse and neglect can lead to toxic stress, which can cause damage to the developing brain and biological systems.

Kathryn Santoro (00:01:10): The pandemic has exacerbated challenges to children's health and wellbeing. Poverty rates are rising, food insecurity and housing instability are increasing, school closures are putting kids at greater risk for abuse and neglect, as well as widening the achievement gap. The short- and long-term impact of the pandemic will likely have massive consequences for the most vulnerable children. During this time when the challenges are increasing, it is even more critical to understand and address early adversity and promote healthy development among children. To learn more about how we can help our children thrive, we're pleased to have a prestigious panel of experts with us today.

Kathryn Santoro (00:01:47): Before we hear from them, I want to thank NIHCM's president and CEO, Nancy Chockley and the NIHCM team who helped to convene this event today. You can find biographical information for all of our speakers along with today's agenda and copies of slides on our website. We also invite you to live tweet during the webinar today using the hashtag #protectingourchildren.

Kathryn Santoro (00:02:23): I am now pleased to introduce our first speaker, Dr. Jack Shonkoff. Dr. Shonkoff is a pediatrician and leader in this field of early childhood development. Dr. Shonkoff is the Julius B. Richmond Family Professor of child health and development at the Harvard Chan School of Public Health and Harvard Graduate School of Education. Professor of Pediatrics at Harvard Medical School and Boston Children's Hospital, research staff at Massachusetts General Hospital and director of the Center on the Developing Child at Harvard University. We are so honored and grateful that he's here with us today to share his work and I will turn it over to him now. Dr. Shonkoff?

Jack Shonkoff (00:03:12): Thank you very much, Kathryn, it's really a pleasure to be here with you today. Whoops, go back. Sorry about that. So the title of my presentation is to connect what we know about early childhood development and lifelong health and think about it within a COVID-19 world. So, I'm going to give you a crash course in 21st Century science and how it can help us understand the topic for today. For starters, looking at COVID-19 through an early childhood lens there are a couple of points I want to put on the table. First, there's nothing new about the disparities associated with poverty, racism and other structural inequities. We see that in just about everything we look at in the healthcare system. But what is a really important opportunity for the public to understand is the striking variations in susceptibility to illness and response to treatment. And really underscore what is a pervasive issue all through the healthcare system and the healthcare world in physical and mental health, which is that there's huge variability. In this case, age, pre-existing medical conditions, life circumstances have all gotten a reasonable amount of attention.

Jack Shonkoff (00:04:32): What the important lesson here in terms of the impact of COVID-19 on very young children is that they are clearly, by age, relatively spared from serious illness, although it certainly exists in young children. So, there might be a false sense that nothing bad has happened to children when in fact the stresses that their families are experiencing probably have an enormous effect on many, many children that will have lifelong consequences.

Jack Shonkoff (00:05:01): The next issue to highlight here is that the health and wellbeing of young children is inextricably tied to the health and wellbeing of the adults who care for them. So just about any question that anyone will ask, which is what can we do to protect our young children from the consequences of this level of adversity, how can we minimize the risk for later problems? The correct answer, no matter where the issues are coming from is always very young children's health and wellbeing is tied into the ability of the adults who care for them, to buffer them from adversity, to provide a well-regulated caregiving environment in which healthy development can unfold.

Jack Shonkoff (00:05:44): The third issue here, which has actually gotten very little attention in all of the public press about the underlying risk conditions or serious consequences in COVID-19 is that the most common pre-existing medical conditions that impose the highest risk, largely obesity, metabolic syndrome, heart disease, diabetes, we've all heard about this over and over again. All of these adult medical conditions are associated with greater adversity early in life. Something to really think about in terms of young children today who are not physically ill but who's families are experiencing enormous pressures, incubators, for increased prevalence of many of these chronic diseases later in life. In a minute or two I'm going to walk you through the underlying science that helps us understand how that happens.

Jack Shonkoff (00:06:41): So 21st century science, particularly the biological sciences have been exploding over the last two decades and have deepened our understanding about the origins of disparities, both in early learning, early behavior, as well as lifelong physical and mental health. And there are three take home messages that I want to share with you this afternoon.

Jack Shonkoff (00:07:03): The first is the early childhood field has been heavily influenced the last 20 years by the explosion of neuroscience, with our understanding of how much early experiences shape brain architecture and how excessive, what we call toxic stress, disrupts the circuitry of the developing brain. Well the science is not very clear that the brain is connected to the rest of the body. So the impact of early adversity is not only well documented in terms of its effects on brain development but also now increasingly we're learning more about its effects on the immune system, the effects on regulatory systems, which is opening up that block pox of why is it that children who experience excessive amounts of adversity early in life, on average, are more likely not only to have problems with early learning and readiness to succeed in school, which is where the early childhood policy field has been focusing, but also these are the building blocks of the most common chronic diseases that we see decades later in life.

Jack Shonkoff (00:08:02): The second concept, take home message, is the importance of understanding the critical influence of variation in sensitivity to the environment. This is the issue related to risk stratification. It is certainly true, on average, that young children who are experiencing significant adversity will be more likely to incur health problems later in life. But the underlying biology is crystal clear that the name of the game is variation in sensitivity to the environment. The interaction between not only environmental exposures, but genetic differences on an individual basis. There are children from birth who are genetically more sensitive to the environment around them, or sensitive to experiences. And in tough environments, they are much more likely to have problems. And in well-resourced growth promoting environments, they're actually more likely than average to thrive. These are children who are extremely sensitive to differences in the environment. Which also includes programs and treatments.

Jack Shonkoff (00:09:09): So there will be differential response to treatments and interventions. We have to recognize that the underlying scientific explanation is there is no one size fits all, both for exposures and for treatments. And in fact, the way we will improve our impact of the scale of the population level is to ask the question not whether interventions work or not, but for whom do they work, for whom do they not? I think this audience understands this quite well because you understand the revolution that's driving precision medicine that occurs in treatment of disease in adults now. It's not a matter of just picking the one exposure or the one best intervention.

Jack Shonkoff (00:09:46): The third issue that science is telling us about how we have to think about early childhood is the importance of critical and sensitive periods in development. Critical periods and decreasing plasticity related to brain development have been known for decades but what the frontiers of science are telling us right now is that in a parallel way, critical periods in the development of the immune system, development of metabolic regulatory systems that are influenced by prenatal exposures, whether they be excessive stress activation, whether they be exposure to environmental pollutants, to whether they be issues related to nutrition, and in the first 12 to 24 months of life there are a number of programming effects on the immune system and metabolic systems. They are much more difficult to change later.

Jack Shonkoff (00:10:41): Let me move to the next slide and bring you inside with a little bit of a crash course on the biology, adversity and resilience. It explains how excessive stress can undermine the foundations of healthy development. What is it about adverse experiences? What is it about stress that gets into the body? How does it lead to problems of disease? How does it affect early learning? Well, starting at 20,000 feet and working down, everything, all learning behavior and health is influenced by the interaction among genetic variation, on an individual basis, environmental stressors and developmental time. And if we then look inside the body and ask it the question of what do we know about the stress response system, we know that it is made up of multiple components.

Jack Shonkoff (00:11:28): So when we are stressed, when we are threatened, there's an elevation of stress hormones through the [inaudible 00:12:02], pituitary access. There is an increase in heart rate and blood pressure, the inflammatory system is activated, metabolic regulation is affected possibly with stress, insulin resistance, problems related to disruptions, so metabolisms on a chronic basis. Epigenetic effects on gene expression, developmental pacing, chronic stress activation actually accelerates the aging process. And of course, the well-known effects on brain circuitry and electrical activity. The important message here is that our stress response system, with all these components are highly interrelated. It is our friend. These physiological responses that I just described here are what we all feel when we are stressed, everyone knows what that feels like, whether you are optimally stressed. It helps us deal with threat in an acute situation. It's intended to then go back to normal, to baseline. When it doesn't go back to baseline and it is chronically activated, what basically helps us in an acute situation, then has a wear and tear effect on multiple organ systems: the brain, cardio metabolic systems, inflammatory systems, immune systems and all of these. If I had more time I could go into more examples, help us make the link between early adversity and the chronic stress activation and why we see the kind of health problems that appear later in life.

Jack Shonkoff (00:13:03): So let me just end this presentation by trying to make the link between why investments in early childhood are not only important for early learning and readiness to succeed in school, which is more on the protection side and on the enrichment side, providing enriched experiences to promote early literacy. But what the science is telling us is that early investments that protect biological systems from toxic stress, investments that help to strengthen the ability of adults to buffer children from the adversity around them, to help the development of the building blocks of resilience [inaudible 00:14:11] is built over time. It's not wired in automatically at birth.

Jack Shonkoff (00:13:48): Investments early on that will protect these systems will generate a substantially larger return on investments than just when we look at the return on educational achievement and economic positivity. You can see from this chart that three of the five most costly adult diseases that you are all very familiar with, are associated with early life adversity. They are much more prevalent among adults who early in infancy had activation of their stress response systems. So, the message here, the take home message, is that science informed investments that reduce hardships and adverse exposures faced by pregnant women and families raising young children offer a promising pathway to enormous savings in health care costs decades later as a result of helping to protect these developing systems from excessive stress activation.

Jack Shonkoff (00:14:41): For those of you who want more information, here is the website for our center, developingchild.harvard.edu. We have extensive materials translating science for non-scientists and our latest working paper, Paper Number 15, which just came out in June, was titled Connecting the Brain to the Rest of the Body in Early Childhood Development and Lifelong Health and Deeply Intertwined.

Jack Shonkoff (00:15:06): So thank you very much for the opportunity to be part of this webinar. I look forward to the next presentations and the discussion.

Kathryn Santoro (00:15:15): Thank you so much, Dr. Shonkoff and just want to echo the great resources available from your center. And especially, I know, on your Twitter that you're sharing some great resources and examples of programs too. So, encourage people to access those and we look forward to your continued work in this area. It's really been essential and will continue to be essential for informing policies and services as we move through this difficult time.

Kathryn Santoro (00:15:46): Our next speaker, Jane Stevens, will discuss what ACEs initiatives are doing to respond to COVID-19. Jane is the founder and publisher of ACEs Connection. ACEs Connection educates and supports more than 47,000 members and more than 300 ACEs initiatives as they integrate the science of ACEs into their work. Jane?

Jane Stevens (00:16:02): Hi. Thank you for the introduction and for inviting me. I'm really honored to be included in this discussion today. The two outstanding events of 2020 so far are the pandemic that exposed the great cataclysms in our social, political and economic structures and the awakening that finally took hold as a result of the tragedies that spurred the Black Lives Matter movement. As tragedies on this scale often do, they are providing an unexpected and remarkable opportunity. In the spring, when we heard people saying, "I wish things would get back to normal." We said, "We don't want things to go back to normal." Normal wasn't such a great place for most people in this country. We said we're going to work with a lot of like-minded folks to create a better normal.

Jane Stevens (00:17:10): The science of adverse childhood experience is at the foundation of all that we do and I should just quickly explain what we mean by ACEs science and the C is five parts, measuring the burden of childhood adversity on individuals, organization systems and communities, the impact of toxic stress from ACEs on the brain, how toxic stress from ACEs damages our health, how it's passed on from generation to generation and in systems through decades. And how the brain and body can heal and how we can prevent ACEs.

Jane Stevens (00:17:47): This relatively new understanding of human development and why humans behave the way they do is central to addressing solutions. And the solutions are counter-intuitive. If you focus less on the individual ACE and more on the healing of the whole person, the whole organization, the whole community, there's a better chance at achieving solutions. And I'll provide some examples later.

Jane Stevens (00:18:25): There we go. Had to wait for that. The reason I'm showing this slide is because I want to amplify that ACEs are so much more than the original 10 ACEs in the CDC Kaiser Permanente study. And so, intertwined with cascading effects. COVID-19 is just one of a number of ACEs that children are dealing with now, as Jack mentioned. And the best approach to protecting them is to protect us, their parents, the organizations and systems that care for them, the organizations and systems their parents work in and the community they live in.

Jane Stevens (00:19:21): The slide is having a little bit of trouble coming up. There we go. So, this is what we do. This isn't just an issue of solving or dealing with a pandemic. This pandemic will be solved in two or three years. The pandemic has offered us a remarkable opportunity to use ACEs science to lay a foundation to take a truly evolutionary and revolutionary approach to solving most of our other ACEs. And that, in the long run, will help humans cope with the greatest challenge to humanity that's coming up, climate change and its effect.

Jane Stevens (00:20:17): So, here's a little information about us, what we do. ACEs Connection is a social journalism network. At present we have more than 47,000 members, so not accurate on this slide, but we do. All people who are integrating ACEs science into their lives, their organizations, systems and communities.

Jane Stevens (00:21:00): I need to go back one. There we go. The people and communities who participate in ACEs Connection, this is all free, by the way, supported by some wonderful donors such as the Robert Johnson Foundation and the California Endowment. Anyway, they learn about these new practices and policies and use them in their own organizations and communities. When they make improvements, they share those with the rest of the ACEs community to accelerate the use of this knowledge. Right now, we believe there are several hundred cross sector initiatives in the US. We aim to have about 1,000 in our network in the next two years and 5,000 in the next five years. Sounds like a lot but that's actually still a very small number. There are 34,000 cities and counties in the US and every community will benefit greatly by incorporating this knowledge. We think that 5,000 is probably a tipping point, which is why we're aiming for that.

Jane Stevens (00:22:20): We work in person, COVID willing, and online with ACEs initiatives in cities, counties, states and nations. We provide them tools such as diversity, equity and inclusion tool and guidelines to launch and grow their ACEs initiative. For mature ACEs initiatives, we recently launched a cooperative of communities with unique tools that quickly measure a community's progress in becoming trauma informed as well as correlate their progress with outcome data organized by sectors in their community. The cooperative also provides services such as learning collaboratives, network leadership training and ACEs informed diversity, equity and inclusion training for initiative. If you want more information about that feel free to contact me later.

Jane Stevens (00:23:17): So, we send out a daily digest and weekly roundup of the latest ACEs science, trauma, informed and resilience building news, research and reports. We get a lot of information from Jack Shonkoff's organization. The resources center has resilient surveys, ACEs science presentations and much more. We have an ask the community on our network so that people can help each other to find information. Our reporters post articles about the use of ACEs science and many get wide distribution. The article about Dr. Dan Sunrock and the addiction article on there has had nearly two million page views and have led him and others in the article to testify before Congress.

Jane Stevens (00:24:07): The articles do more than that, though. They show what's possible and it leads many other people to integrate ACEs science into their organization. For example, we reported how schools use ACEs science to eliminate suspensions and expulsions, with a result, in many communities, of the school to prison pipeline is being shut down. And kids are happier and enthusiastic about learning and get better grades.

Jane Stevens (00:24:36): In the story about Dr. Sunrock's data, he and others at the University at Tennessee showed that 100% of patients were no longer addicted and could hold down jobs. They're also able to predict relapse and how a long-term course of treatment reduces relapse.

Jane Stevens (00:24:59): [inaudible 00:25:26] programs that integrate ACEs science reduce recidivism from 30 to 50% to just 1%. Safe baby courts that integrate ACEs science show that one year after participating 99% of the kids suffer no further abuse. It just goes on and on and I can provide many other examples.

Jane Stevens (00:25:35): Break up. Since the pandemic began we've pivoted in a number of ways. We write articles such as how trauma informed pediatric clinics are grappling with TeleHealth, how the pandemic has [inaudible 00:26:17] system inequities. For example, in this story, we mentioned that when Sacramento County in California received CARES Act funding, 85%, or more than $100 million went to law enforcement and only 2%, or $2.5 million, to public health. We'd like to see that changed.

Jane Stevens (00:26:27): Since March we've been doing two or three community conversations a week on topics requested by our members. These include topics about childcare, domestic violence and trauma informed policing. The demand for addressing issues and education is so popular that the education Better Normal meets every Thursday and it attracts up to 100 people from around the world. We limit it to 100 because we want to actually have a conversation. Each Better Normal addresses how to deal with the pandemic and how to shift for long term change. We're hosting our 50th Better Normal on Tuesday.

Jane Stevens (00:27:19): We provide resources that we continually cull and update for educators, parents and healthcare providers. We do articles and Better Normals about what communities are doing to better address the pandemic in the short term as well as how they're integrating changes over the next several years.

Jane Stevens (00:27:51): (silence)

Jane Stevens (00:28:08): So this is a quote from Quinn Zora. She's a public health nurse who was a pioneer in integrating ACEs. She said, this is the introduction to near at home, an ACEs model that 60 public health experts put together for home visiting community. If this knowledge about ACEs science is integrated into individual organizations across sectors, in systems and communities, we will create a better world for our kids, no doubt. And we definitely want to equip them with all the resilience they'll need to figure out a way to thrive during the upcoming climate change.

Jane Stevens (00:28:56): Human's historical approach to changing people's behavior, whether it's criminal, unhealthy or unwanted behavior, is to use blame, shame and punishment. Or to throw out the company of information at them and expect them to change. Instead of using blame, shame and punishment, how do we restructure organizations to understand, nurture and help people heal themselves? And you do that by educating them about ACEs science and then show them how to integrate it. Only that way can we create communities that manage problems and change them to those that manage solutions.

Jane Stevens (00:29:47): Understanding this new knowledge about ACEs science can be life changing. It starts with a mind shift. That's because when we learn about ACEs science, we understand four essential aspects about ourselves, that we weren't born bad, we weren't responsible for the things that happened to us when we were children, we coped appropriately, given that we were offered no healthy ways to cope, and it kept us alive. And the fourth one is that we can change. Now this applies to organizations too. The same kind of approach and integrating sciences into an organization is complicated, it's ongoing for years and it's extremely rewarding. But it's not just another program. Organizations must integrate this into their own workforces before they can expect to be able to integrate it into their practices and policies for their clients, students, patients and prisoners.

Jane Stevens (00:31:04): (silence) Jane Stevens (00:31:05): Basically, thanks to pioneers like Jack, we know how to create a much better normal. And by using ACEs science knowledge, we can take advantage of a pandemic that has laid bare the great chasms of structural inequities in this country and in the world. We can solve our most intractable problems so that we create organizations that manage solutions in context of the whole instead of playing whack-amole by trying to solve problems individually.

Jane Stevens (00:31:40): And I have some resources that will be included in the PowerPoint that you all will receive. Thank you so much. I really appreciate being here.

Kathryn Santoro (00:31:54): Thank you so much, Jane and to your team at ACEs Connection for being such a valuable resource and convener and also for all the great resources that you are disseminating during this time. For our final presentation today, we will turn to hear from Premera, from their social impact program. Under the leadership of Jeff Bro, Premera’s president and CEO, Premera Blue Cross launched a social impact program to support behavioral health in underserved communities with an emphasis on prevention for the biggest impacts. The social impact program supports evidence-based programs in Washington and Alaska with a focus on funding programs that address adverse childhood experiences.

Kathryn Santoro (00:32:46): To hear more about these efforts, we are now joined by Paul Hollie, the head of Premera's Social Impact Program and Maurice Lee, the COO of Navos, a mental health clinic that helps people reclaim their lives from mental illness, addiction and trauma and abuse. I'll turn it over to Paul to start.

Paul Hollie (00:33:08): Thank you so much for inviting me to be along with these very distinguished experts. There's a lot to learn, there's a lot that we're continuing to learn from our perspective. As a healthcare payer, Premera has placed a huge emphasis on bringing solutions to all of our members. It's part of our effort to make healthcare work better. That's what we talk about all the time. And so that being the mission, our experts have spoken to the impacts that ACEs have and how they show up both short and long term.

Paul Hollie (00:33:43): So, I want to speak very briefly about our approach supporting work in this space in our communities. So as you mentioned our social impact program, which is Premera's philanthropic program, it just got started in 2017, just a couple years ago. And with that focus from the very beginning, even in the planning stages, to really focus on the behavior health aspect of those in our communities. As of 2019, more than a third of our funding has gone to non-profits to serve this behavioral health area. And we definitely see it being an area that we're going to support and build upon. One of those experts in the non-profit partnerships will be here very shortly.

Paul Hollie (00:34:32): So as community organizations see their workloads increase, they're also telling us they need more help in this area of ACEs and trauma informed care. So, in addition to helping them get that direct support, we've also helped them in the training for the staff of these areas, and this has been a key bit of feedback we've been hearing. Not only do you have to have experts in place who handle the acute aspects of it, it really comes down to having a lot of the staff to have training, understanding, experience in dealing with these cases. So, in many of the cases, training has also been expanded to volunteers because once again, all people who interface with that client base need to at least have some working knowledge of how this is all factoring through.

Paul Hollie (00:35:25): So with that I want to bring in one of our community partners who's definitely an expert in this area. Maurice Lee is the new chief operating officer at Navos, a leader in providing healing and support in the area of behavioral health. Mr. Lee has a long and distinguished background and I'm really happy that he's joining us here today, not only to speak to what he's doing in his experience but also continuing the partnership between Premera and Navos. So, with that I want to introduce Mr. Lee. Maurice.

Maurice Lee (00:35:57): Thank you, Paul. And I want to extend my thanks to the distinguished subject matter experts that preceded me. You have made my presentation really easy. The first thing that I want to reflect on is Jane's comment, we can change. And with that I would like to frame my own personal experience with ACEs.

Maurice Lee (00:36:18): I grew up as a youth in New York City in a pretty unsteady and traumatic environment. I did take the ACEs quiz myself a few years back and my score was an eight. I can imagine my four sisters' scores would have been relatively the same. All of us experienced situations in life and unfortunately, three of my sisters have passed away before the age of 60. Three of them to cancer, which I will call out that both of my parents smoked in that environment. The other one passed of lupus. I have my own health struggles, I struggled with addiction early on in life, obesity, high blood pressure and some of the other factors that may be attributed to ACEs.

Maurice Lee (00:37:18): What's important for me to note is that zip codes often define health and lifespan and, in the neighborhood, where I grew up this was prevalent. And going into other environments produces other results.

Maurice Lee (00:37:44): Most of these factors have been already called out and I don't find it relative to continue to go over these but what I think is important for me to call out is that a high ACEs score is simply an indicator of greater risk. Not all children that will experience multiple adverse childhood experiences will have poor outcomes and not all children who experience no adverse childhood experiences will avoid poor outcomes. A high ACEs score is simply an indicator of greater risk.

Maurice Lee (00:38:16): It's important that additional assessments are performed by professionals to get a full evaluation of the risk. So, this is an excellent tool to be able to point you in the right direction, to identify that there is risk. But additional supports are going to need to be performed to accurately get a picture of what the impacts of people lives and environments trauma has been. One of the things that I was discussing earlier was growing up in some urban inner-city environments, such as in New York or in Chicago in [inaudible 00:39:25], a lot of youth are experiencing PTSD just simply walking out of that door every day. There's death all around them, there's poverty all around them, there's prostitution all around them and the norms of that environment are not always conducive with the norms of the greater society but they may be socially acceptable norms in that environment. Thus, those elements are perpetuated generationally.

Maurice Lee (00:39:34): One of the things that I want to call out, it just doesn't take into account some serious factors such as tobacco use. The prevalence of both parents smoking in the house is transferred, generationally, to their kids. In my household, all my siblings smoked. All of them had early pregnancies. So, these things give the most common question but we really need to dig deeper into some of these areas that Jane and Paul were calling out such as even the Black Lives Matter movement that is currently under way.

Maurice Lee (00:40:28): One thing that I want to talk about is establishing an environment for healing and I think that's probably one of the most important things that Jane also called out. One thing I want to note is that at Navos, all of our staff members must attend mandatory training on trauma informed care to help establish a trauma informed environment. When I say all staff, that goes down to the drivers, if you're a cook, if you empty the trash. Everybody is going to have an understanding that the populations that we serve must be considered to have experienced some trauma in life and we will identify those traumas through additional assessments but walking in the door, everything has to be considered from the pictures on the wall to the relationships that are formed to making sure we provide a safe environment.

Maurice Lee (00:41:31): I was sharing with Paul the mistakes that we made early on in treatment 30 years ago in some of our therapy communities which really weren't designed for trauma. We had positions and a job structure for the residents, the clients, the patients that were called ram rods. And you already had women coming in, it wasn't gender specific treatment at that time, they were coming into this environment and that term had a negative connotation to it for young women who may have been molested or experienced some sexual trauma of rape and other incidents that that term just was counterproductive to the goals that we were trying to achieve through treatment.

Maurice Lee (00:42:23): So just having a high prevalence of traumatic experience in patients that receive mental health services or substance abuse services is essential. So, in doing so, we make sure that everybody is trained. The first factor that's primary is the relationships. The patients need to be feeling safe, have trusting relationships in order for them to be calm and have cognitive and not have fears and uncertainties. Much like the experiences that I had growing up as a kid. There was no certainty in my environment. There was no certainty that there would be food, there was no certainty that the parents will come home, there would be no certainty that the heat would be on in the middle of winter in New York.

Maurice Lee (00:43:20): A nurturing environment is also important for individuals to be able to regulate. Remember trauma informed impacted individuals experience a lot of stress, anxiety and fear. If you're not able to provide a calming and regulating environment, they will be more apt to relax because we offer a bit of sanctuary for their difficult lives.

Maurice Lee (00:43:49): The third factor that I think is really important for me to call out is the trauma informed environment has to provide a positive residence. So, the support that's needed, not having chaos in your environment and people having a concern about their impact on each other and the clinical teams working cohesively. And it's not dissidence. And the staff honor each other, they share in each other's strength and they celebrate with each other.

Maurice Lee (00:44:28): One of the things that I will point to is one of our programs at Navos is our child, youth and family department. We have a specialized program called Early, an infant and early childhood program that serves low income families with young children who have experienced trauma. We often receive our referrals for infants and toddlers with child welfare involvement.

Maurice Lee (00:44:58): We work to break the cycles of inter-generational trauma. One of the things that I'm proud to be able to say is that my daughters, I have one that graduated high school and is in her first year of college but all my other daughters have completed college. They've avoided early teen pregnancy and I think the environment that was created by me and my wife of not having alcohol, drugs, tobacco in the home, has been passed on. And hopefully that results in some positive health outcomes that were not shared in my family with my siblings. By working with the young child and the parent together, because it's not just about influencing the child, it's about influencing the parent who probably also, if quizzed, would have significant ACEs scores. You can start to break some of the generational, what we would call in my culture curses that have been passed on and been predominant in the family. So, we don't only address the direct impact of trauma that the young child has experienced, but we also help the parent reflect on the trauma they have experienced growing up. And work through it to learn new ways and healthier ways of parenting.

Maurice Lee (00:46:26): We know that by supporting the parents and changing the environment and supporting the infants and young children, we are working to reduce the stress and the trauma and have the added goal of longer health outcomes for the young children we are serving.

Maurice Lee (00:46:43): With that I am going to stop because I'm going to make sure that there is enough time in this panel to be able to ask questions. And thank you for allowing me to participate.

Kathryn Santoro (00:47:02): Thank you so much, Paul for Premera’s leadership on this topic and for Maurice for sharing your important work and your personal experience. We will now engage with our audience in a Q&A. Please continue to submit your questions in the Q&A box. I wanted to start with, we had a couple questions come in about the role of the healthcare system and start with Jack for this one but all the speakers can come off of mute and weigh in as you would like. Can you talk about the role of pediatricians? Any anticipatory guidance on building resilience and also just the importance of screening when it seems like children who might allude interventions are the ones not getting the screenings, especially in this time period when children and families are having difficulties accessing healthcare and other social services.

Jack Shonkoff (00:48:09): Well, whoever asked the question really hit on a really important issue. I have several connections so I'll just mention a couple of things. The critical role of the primary healthcare system for screening for early identification of kids at greater risk is obviously really important. The ability for pediatricians to spend time with parents, with other caregivers, to be able to build a relationship, to provide support, to provide information, to identify services when they're needed. So, on paper, those are exactly what the primary care system could be doing in a very effective way is prevention, early intervention. The challenges are that it's done variably well and the factors that affect how well it's done or not done, despite everything from the kind of professional education and training that the pediatricians, the healthcare providers get. There's a lot of, what we've talked about during this webinar, it's not really built in in a significant way in the training of pediatricians, so that's one issue.

Jack Shonkoff (00:49:16): Second one, which all of you out there in the audience are familiar with, is spending time with families means spending time with families so the pressures on the length of the visit and compensation for the time spent building relationships, it's not just giving information, it's building relationships that parents know the caregivers can trust.

Jack Shonkoff (00:49:35): And then the other issue is the way in which we evaluate the effects of the interventions and the services. And it's been an honor for me to be a part of this panel with folks who are out there on the frontline and really provide a wonderful description of the services that are available. But the challenge is that services are variably effective. It goes back to what we understand about underlying differences. And so we really need more information about what's working for whom so that we can scale it, what's not working as well for others so that we can come up with alternatives. So, the issue of early identification, the issue of referrals, the issue of relationship building [inaudible 00:50:39] is absolutely on target but we have a lot of work to do in terms of how well we train people for this, how well we compensate them for their time and how we evaluate the differential effects of what is provided out there. It's a really important issue. So, thanks for that question.

Kathryn Santoro (00:50:31): Thank you. Jane or Maurice, do you want to weigh in at all about how other types of providers or other people in the community can help build resilience? I know Jane we had a lot of people asking if they could learn what you're learning through your Better Normal conversations.

Jane Stevens (00:50:53): Yeah, we have quite a few resources, obviously, on ACEs Connection and there's just a ton of stuff happening every day so I encourage people to join and find their area and contribute as well as learn. In California there's, I would say, a massive state-wide experiment right now that I think other states are going to be doing as well which is to have this huge effort to educate pediatricians and practice physicians about ACEs science very thoroughly. And then set up a system where, we're actually participating in this part of it, whereby the pediatrician and practice family clinics are connected with trauma informed organizations in their community while we're really pushing for communities to make sure that their organizations are becoming trauma informed.

Jane Stevens (00:51:59): So, I was really happy to hear from Paul and from Maurice because what you're doing, Maurice, is just fabulous and every organization should do it. I'll be in touch with you to talk to you about that.

Maurice Lee (00:52:18): Thank you, Jane. One of the areas that I think we really could make a significant impact is in our schools. I mean whether we realize it or not, our children, under normal conditions, usually spend more time in the school environment than they do woke in a home environment with their parents. So, having educators thoroughly train so that they can identify indicators early on and intervene with the child, with the families and even create environments in schools that don't perpetuate some of these problems, such as the bullying and the cyber bullying that we've got going on right now in the schools. And even make sure the kids have the proper equipment so that they're not running an uneven playing field with other children. It's unfortunate having a kid who don't even have internet access and the impacts that has on them. And maybe some of the people don't even think about it, but our schools, I think, are a point of entry where we can make a great impact.

Jack Shonkoff (00:53:27): I want to underscore one point that I believe Maurice made in his earlier comments about the fact that not every child with a high ACEs score has trouble. Really important for us to understand, ACEs are real, ACEs reflect significant differences in risk and ACEs is not an individual diagnosis and there is danger of labeling children with high ACEs scores in a way that doesn't reflect differences in how children respond to adversity and how the adults around them protect them from the adversity. So, it really requires individualization in the context of understanding how that adversity is in general for children.

Kathryn Santoro (00:54:15): Thank you. A few follow up questions about the school point. What can we do as a community for children? We know a lot of children aren't returning to school in person, but some children are just not participating in school or in distance learning. And schools, as Maurice said, children spend a lot of time there and that's one place where teachers or counselors are able to help. They're able to recognize neglect or abuse. And what are some ways we can help students now that we don't have a new normal yet with our schools going forward?

Maurice Lee (800:54:59): I will say at Navos, we do go into the schools and provide individual and group services in the groups. So, we're in a couple of school districts and going in daily and work with the school counselors doing thorough assessments and teaching them the signs to look for referrals.

Maurice Lee (00:55:24): I think another thing that we can do with our schools is make sure they have appropriate resources as well. It's unfortunate the resources that we pour into our prison systems in comparison to how we compensate our teachers and the repair of some of the facilities and the equipment available to address some of these concerns.

Jane Stevens (00:55:49): And also in the Better Normal, we had, as I said, we have an education Better Normal every week and I remember one was so profound because it's people who are learning more about brain science and understanding that it's really not very healthy for kids to sit still for X amount of time. And so, there's been some very innovative approaches to not only distance learning but looking at what a classroom will function like after kids actually get back into the school.

Kathryn Santoro (00:56:34): Great. Thank you. This question is for Dr. Shonkoff but others can weigh in as well. And I know you presented a lot of the great work that I know your center is trying to get out there and disseminate even more. How can we help the healthcare system and other leaders understand this relationship between childhood adversity and adult disease states? A lot of the ROI information that you shared. And what can we do to increase the understanding and really increase investment in these types of programs and efforts going forward?

Jack Shonkoff (00:57:12): Well I'll give you my own perspective on this. I think there are two issues that need a lot of attention. The healthcare establishment, academic medicine, needs to embrace the fact that adversity and social determinants are not primarily a social service referral. And that they are really about threats to physical health. And I think the advances of science need to get more into medical education and the academic medical establishment and I think that's inevitable, just going to take some time. But there really is a sense that this has traditionally been a social service issue or a human service issue, not a medical issue. And the science is screaming at us, no, that's 20th century thinking. That's not 21st century thinking.

Jack Shonkoff (00:58:06): I think the other issue is the recognition that the healthcare system has to be much more connected to a wide range of community-based services that will be seen as you refer out and then it's taken care of. The last thing is measurement. This is something that is really on the horizon but we have to have ways of measuring who is showing a stress activation? And who is showing resilience in the face of adversity? And how do we know if these interventions are working until we demonstrate that excessive stress activation has been brought down to baseline? I think that's something that's on the horizon. Healthcare financing that's going to have to address that measurement issue. But once we have it, we'll have a much stronger case for why this is part of prevention and healthcare. That's kind of what the future holds. Right now, a lot of our evaluations are done through parent checklists and other kinds of measures that are not really capturing the underlying changes in the body that people have a better understanding of being connected to actual physical health. So, this is on the horizon.

Jack Shonkoff (00:59:17): I think all of you out there, please be prepared for this because this will be a big part of a game changing new normal in pediatrics and then healthcare move, probably. Mostly to connect pediatrics to obstetrics and pediatrics to internal medicine. This is a lifelong issue, it starts prenatally and it doesn't stop when kids get into adult life. It's a continuum.

Kathryn Santoro (00:59:43): Thank you so much. I know we are out of time. I do want to just ask our speakers one final wrap up question, and feel free to add any other concluding remarks that you would like but we've had a lot of questions about what we're learning, what are solutions. If there's something you could share that you feel you've learned in the past six months as we've dealt with the pandemic, what are some lessons learned or other advice you would give to all the workers out there and parents and families about how they can help children build resilience, build their own resilience and prevent ACEs for the next generation? We'll start with Jane.

Jane Stevens (01:00:31): Well I would say connect with other people in your community. Connect with other organizations. It's those connections that will accelerate this knowledge. So that would be my suggestion.

Kathryn Santoro (01:00:47): Okay. Dr. Shonkoff?

Jack Shonkoff (01:00:49): I think I've taken up too much air time. I'll just congratulate my colleagues on the panel for the work that they're all doing and say that we need to not only underscore the importance of this, but we need to start finding out a more rigorous way, where are we making the biggest impacts? Where are we making less impacts? Where are we making no impacts? And see that as an opportunity to be better. Just the way we treat cancer. We don't say to the cancers that continue to be high fatality rates, we don't say, "What's the point in investing in that? People keep dying." I think we need better understanding of where we're most effective and where we're less effective and see that as the way strong field operates. [inaudible 01:02:03].

Kathryn Santoro (01:01:36): Thank you. Paul and Maurice? [crosstalk 01:02:09]

Paul Hollie (01:01:42): On the philanthropic piece of it, certainly a lot of our community resources are really struggling in light of reduced funding, whether it's from contributions and things like that. They've had a lot of layoffs and that type of thing, they're under a lot of financial pressure, as we all are. So, I would certainly recommend trying to garner as many resources as possible to help them to help the rest of us, whether it's volunteer time, energy, ideas, finances, those types of things. And I'll leave it to Maurice to get more specific.

Maurice Lee (01:02:17): The one thing that I want to call out is that not only in the situation with COVID, but just in general, children are in a dependent relationship and their well-being is dependent on the individuals that they're surrounded with in the environment. And I think the greatest thing that providers and responders and parents can do is make sure that they're okay. Make sure that they take the time and do the work so that they're there for their dependent children, that they're stable and that they're doing the things, as simple as exercising, eating well, meditating, connecting, doing service work and whatever makes them be a pillar that that kid can gravitate toward and avoid some of these traumatic experiences.

Kathryn Santoro (01:03:18): Thank you so much. Thank you to our entire panel of speakers. You all took time from your busy schedules to be with us today and I know on behalf of our audience, they all really appreciated your presentations and have learned a lot and planning to take this back to their colleagues. For our audience, please take a moment to share feedback from this event by completing a brief survey, which can be found on the bottom of your screen. We'll also be posting our resources from this webinar, from our partners that presented today and you can also find our latest infographic on early childhood development and ACEs. We also invite you to register for our next webinar on strategies to address the negative impact of systemic racism and social and economic inequities on Latino health.

Kathryn Santoro (01:04:12): So, thank you all for joining us today and please stay safe.