“It is easier to build strong
children than to repair
broken men.”
Frederick Douglass
(1817–1895)
PROMOTING EARLY AND
LIFELONG HEALTH
THE PROBLEM OF ADVERSE CHILDHOOD
EXPERIENCES AND THE PROMISE OF RESILIENCE
HIGH LEVEL REVIEW OF POTENTIAL AREAS OF
FOCUS FOR A CHILD HEALTH SERVICES RESEARCH
AND ACTION AGENDA
CHRISTINA BETHELL, PHD, MBH, MPH
FEBRUARY 10, 2015
NATIONAL CHILD HEALTH
POLICY CONFERENCE OVERVIEW
National and State Data on Adverse Childhood Experiences
and Resilience FOR CHILDREN (2011-12 NSCH
(HRSA/MCHB/CDC)
47.9% of US Children 1+
(of 9) ACEs Age 0-17 years
WA
MT
OR
ME
ND
MN
ID
WY
WI
SD
NE
NV
22.6
25.3
CA
No adverse family
experiences
UT
AZ
52.1
CO
IA
PA
IL
KS
OK
NM
MI
MO
WV
KY
TX
AR
DC
SC
GA
LA
HI
Two or more adverse
family experiences
VA
NC
TN
MS AL
One adverse family
experience
NJ
MD DE
!
OH
IN
VTNH
NY MA
CTRI
FL
AK
State Ranking
Lower=Better Performance
Significantly lower than U.S.
Lower than U.S. but not significant
Higher than U.S. but not significant
Significantly higher than U.S.
Statistical significance: p<.05
State Variation In Prevalence of 2+ (of 9) ACES
16.3% (UT) – 32.9% (OK) across states.
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Adverse Child Experiences: NSCH
National
Prevalence
State Range
Child had one or more Adverse Child or Family Experiences
47.9%
40.6% (CT) - 57.5% (AZ)
Child had two or more Adverse Child or Family Experiences
22.6%
16.3% (NJ) - 32.9% (OK)
Extreme economic hardship
25.7%
20.1% MD – 34.3% (AZ)
Divorce/separation of parent
20.1%
15.2% (DC) – 29.5 (OK)
Death of parent
3.1%
1.4% (CT) – 7.1% (DC)
Parent served time in jail
6.9%
3.2% (NJ) – 13.2% (KY)
Witness to domestic violence
7.3%
5.0% (CT) – 11.1% (OK)
Victim or witness of neighborhood violence
8.6%
5.2% (NJ) – 16.6% (DC)
Lived with someone who was mentally ill or suicidal
8.6%
5.4% (CA) – 14.1% (MT)
Lived with someone with alcohol/drug problem
10.7%
6.4% (NY) – 18.5% (MT)
Treated or judged unfairly due to race/ethnicity
3
4.1%
1.8% (VT) – 6.5% (AZ)
Adverse Childhood Experiences
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Project Background
Core Leadership and Coordinating Team:
CAHMI:
Christina Bethell; Michele Solloway; Dave Ford; Caitlin Murphy (others)
AcademyHealth:
Lisa Simpson; Aditi Srivastav (others)
CAHMI Strategy (since 1997)
Family-Centered, Data Driven Partnerships to
Promote Early and Lifelong Health
Transformative Goals
For Child Health
Promote Child
Health and
System
Excellence
Transformational
Partnerships
Actionable Data &
Data-Driven Tools
Inspire and Inform
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AcademyHealth
AcademyHealth is a leading national organization serving the fields
of health services and policy research and the professionals who
produce and use this important work.
Together with our members, we offer programs and services that
support the development and use of rigorous, relevant and timely
evidence to:
1.
Increase the quality, accessibility and value
of health care,
2. Reduce disparities, and
3. Improve health.
A trusted broker of information, AcademyHealth
brings stakeholders together to address the current
and future needs of an evolving health system,
inform health policy, and translate evidence into action.
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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CAHMI and AcademyHealth Partnership
(with you!)
• Focus:
• Transforming the roles of health providers and health systems to identify, prevent and
address ACEs in their communities and promote healing and positive health attributes
that may buffer, prevent and attenuate the intergenerational cycle of ACEs.
• Partnership activities will result in:
• an agenda on research and policy priorities to address ACEs
• communications infrastructure
• Special journal issue APHA and set of field building/advancing
articles
• Materials to engage the field in continued development,
collaboration and collective action
• Funding: CAHMI and Robert Wood Johnson Foundation
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Project Scope
• The project will focus at
three levels on this issue:
• The clinician/family level
• The healthcare organization
level, including hospitals,
clinics, and health plans.
• The health policy level
• For each level, we are asking:
• What do we know about ACEs and
promoting child development and
well-being.
• What do we know about how ACEs
are currently addressed?
• What evidence exists?
• What research questions are of
highest priority to address?
• What actions can be taken at each
level?
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Broader CAHMI
Focus and Partnerships
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Achieving a WHOLE Population Effect
Data Collection and
Analysis
Adjustments and
Spread to Scale
& Public Acceptance
Research, Interpretation
And Dissemination
Training, dialogue,
tools, techniques
1. Population Effect
Field Trial Evaluation
And Learning
Field Trials:
Trauma Informed Communities
and Care
Tools, Trainings,
Curriculum
Consulting, Strategy,
Collective Impact
Our Audacious Yet Humble Aspirations
We would judge the overall nine month (now 24 months) project coled by CAHMI and AcademyHealth to be successful if one or more of
the following is accomplished:
• A prioritized child health services research and policy agenda is widely
distributed to key stakeholders and funders;
• A set of field advancing/research papers published and widely distributed
• The agenda and communications materials are distributed to key actors
who use them in their advocacy/action strategies; and/or
• New connections are formed between essential actors in this country and
internationally that advance a collective impact around childhood trauma
prevention & healing and family well-being.
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Addressing key health services & policy research
domains for each key action area and priority
populations and possibilities (pre-meeting input)
Critical HSR/P Area Emerging from PreMeeting Co-Digital Input and Dialogue
Design and
develop new
research and
knowledge
Translate and
integrate existing
knowledge
1. Organization & financing of health
systems and services
2. Access & coordination of services &
resources
3. Practitioner & family engagement,
communication & behavior
4. Measurement, informatics & clinical
decision making
5. Health professions work force capacity,
training & support
Problems
Possibilities
Priority questions
Priority Populations
Existing and Promising Practices
Existing and Potential
Partnerships
6.Clinical evaluation & outcomes research
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Emerging Scope of Agenda
Organization and
financing of health
systems and services
Health professions work
force capacity, training
and support
Access & coordination
and services and
resources
Six Fundamental
Health Services and
Policy Research
Domains
Practitioner & family
engagement,
communication &
behavior
Clinical evaluation and
outcomes research
Measurement,
informatics and clinical
decision making
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Agenda and Communications
Process and Methods
Discovery phase
Synthesis phase
Dissemination phase
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Steps for Building an Agenda
1) Review goals, strategies and/or priorities and conduct a research needs
assessment.
2) Review existing supporting research and identify gaps in current available
research (or gaps in awareness of gaps).
3) Determine additional research needed and assess funding innovations and
resourced options and research resources/skills capacity.
4) Prioritize existing and additional research based on criteria.
5) Align research to goals, strategies, priorities, and add effectiveness
indicators.
6) Link research to other plans and initiatives.
7) Establish timeline and trajectories envisioned for research and action
8) Share with the broader constituency groups for feedback and information
sharing.
9) Adjust research agenda accordingly based on feedback.
10) Promote and foster implementation of the research agenda, and conduct
ongoing review research and reevaluate research agenda.
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Discovery: Process and Methods
March-June 2014: Convene starting working group and specify
goals and priorities for summit meeting and agenda
March-June ‘14 and Ongoing: Conduct an environmental scan of
research and initiatives
June 5-6, 2014: Convene early stage partners to review and
further specify goals, priorities and to strengthen relationships,
collaboration and facilitate shared vision
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Synthesis: Process and Methods
July-September ‘14: Convene working group to
• agree on core summit meeting summary and core themes and
components for emerging research agenda
• identify topics and focus for a series of papers to commission and
publish on what is known and recommendations for research and
action.
• further refine the environmental scan and project niche
October-December ‘14: Invite and gain agreement from identified
candidate paper author leads.
March ‘14-ongoing: propose and procure additional funding to
ensure full funds available to commission all envisioned papers and
public special journal issue
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Synthesis: Process and Methods
January-March ‘14: Launch start of commissioned papers (to be
completed Summer, 2015)
April-December ‘14: Research and write baseline paper on ACEs
in children in the US (Health Affairs, December ‘14)
July-November ‘14: Assess capacity of NSCH to produce local
reports on ACEs and develop for key ACEs summit meetings
focused on counties/cities.
July ‘14-January ‘15: Develop short video based on June meeting;
Develop a basic web presence to communicate about the project
and continue to update and convene working groups as possible
and needed.
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Dissemination: Process and Methods
September-ongoing: Submit abstracts and proposals to report
on and further evolve a collective action approach to advancing
the promotion of early and lifelong health through an effective
approach to ACEs.
October-February 2014: Plan for and conduct a special panel at
National Child Health Policy Conference in DC—early review and
dialogue on agenda
February-December 2015: Publish papers; complete version 1.0 of
agenda; complete “Champions Toolkit”; evolve project;
disseminate;
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Agenda Setting Input and Status
CO-Digital Collective Insight Questions
Question 1: What should the specific goals of our community
be related to ACEs and resilience? (e.g. the child health
services research and policy community.
Question 2: What research and policy domains and questions
are highest priority.
Questions 3: What are the research questions, policy actions
and existing efforts to consider as priorities in an agenda.
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Emerging Agenda Components
Three interlocking components comprise the emerging
research and action agenda as outlined below.
• Component #1: Functions and Types of Research
• Component #2: Priority Topics and Focal Areas
• Component #3: Short Term Collaborative Actions
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Top 3 Ideas: What Should the Goals Be?
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Top 3 Ides:
What are priority domains and questions
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Top 3 Ideas:
Existing Efforts and Knowledge to Build On
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Component #1: Functions and Types of
Research
Design & Develop: synthesize existing knowledge and design and develop new
translational knowledge, methods, and tools
Implement & Evaluate: adapt, implement, and evaluate existing and emerging
strategies to prevent and buffer impact of ACEs to promote well-being
Educate & Communicate: assess existing awareness and contribute to public,
provider and stakeholder education and awareness, knowledge and action.
Disseminate & Support: develop methods and capacity to scale, spread and
support effective prevention, intervention, and training models in the field
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Component #2: Priority Topics and Focal
Areas
Meanings and Measures: Advance standardization of definitions, measures, and
data
Core Science: Promote research to address gaps in science especially pertinent
to policy and practice
Public Health: Understand public health impact and opportunities for
translation of knowledge into public health practice
Communities: Know what a healthy community is and how to address ACEs
through community based collaborations and efforts
Economics: Define and measure economic impact of ACEs and return on
investment through effectively addressing ACEs
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Component #3: Short Term Collaborative
Actions
Move the Game Board: Define a conceptual map and model to clarify
definitions and foster shits in mindset and norms to facilitate collective
action
Continuous Translation and Improvement: Synthesis, dissemination,
translation, and ongoing assessment of existing models, methods, and
practices
Training and Capacity Building: Provider, community, and family education
and training
Policy platform and demonstration: Define recommendations to align
health reform and systems design with needs and health improvement
opportunities
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Possible Questions to Consider
What should be the goals of the child health policy
community be related to ACEs and resilience and positive
health development?
What research questions, program and policy actions and
current programs should be considered as priorities in an
agenda? Why is now a good time for a broader focus on
ACES in health policy?
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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(OR) Possible Questions to Consider
Why is now a good time for a broader focus on ACES in
child health policy?
What will it take for the child health policy community
and health care system to respond to ACES?
What do health policymakers, program leaders and the
public need to know about ACES?
What are the most significant barriers to an improved
policy response to ACES?
If there is one thing you could change in health policy to
make progress on ACES, what would it be?
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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Partnering and Participation
Visit the AMCHP CAHMI DRC booth #6 and poster #PA5
(Sunday PM and Monday AM)
www.cahmi.org (select adverse childhood experiences
under “projects”)
www.academyhealth.org/ACES
info@cahmi.org
msolloway@cahmi.org
aditi.srivastav@academyhealth.org
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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There is no greater agony than bearing
an untold story inside you
Maya Angelou
5/13/13
Christina Bethell, PhD, MPH. ACES & Resilience CAHMI AH Project Overview
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