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Fighting ACEs in Palm Beach County (FL)

A network for professionals, leaders, and community members to collaborate across sectors to prevent and mitigate the effects of Adverse Childhood Experiences (ACEs), enhance caregiver and community capacity to effectively address ACEs, and build resilience in Palm Beach County, Florida.

Tagged With "Center for Child Counseling"

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It took 3 years, 6 versions to develop ACEs screener that works for parents & providers

Laurie Udesky ·
It’s irrefutable: Widespread research shows that adverse childhood experiences (ACEs) are common. That’s why researchers in a recent study insist: “It behooves pediatric providers to take an active role in preventing and identifying childhood adversity in order to reduce the health consequences of toxic stress.” In other words, if you want your kids to have a good shot at a healthy life, make sure they — and you — are educated about and screened for ACEs and resilience. In a recent study —...
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Mapping the Link Between Life Expectancy and Educational Opportunity [childtrends.org]

By Renee Ryberg, Nadia Orfali Hall, Claire Kelley, Jessica Warren, and Kristen Harper, Child Trends, January 2020 In 2015, an average 15-year-old could expect to live to age 79. However, teens living in the 1 percent of neighborhoods with the lowest life expectancies could expect to live to 70—a lifespan nine years shorter. Educational attainment, a key social determinant of health, is one of the most powerful predictors of life expectancy. This association has strengthened over the past 20...
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ACEs Science Champions Series: Meet Florida's Johnny Appleseed. She plants seeds of ACEs science!

Sylvia Paull ·
Dr. Mimi Graham is Florida’s Johnny Appleseed, but instead of planting apple trees, she’s been seeding hundreds of ACEs-science-informed schools, courts, juvenile detention centers, hospitals, childcare centers, home visiting programs, mental health agencies, law enforcement agencies, and drug treatment centers. Graham, who has served as director of the Florida State University Center for Prevention and Early Intervention Policy in Tallahassee since 1993, focuses on early childhood,...
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New Study Reveals Annual Cost of Childhood Adversity in California Is Approximately $113 Billion [prnewswire.com]

Marianne Avari ·
SAN FRANCISCO , Jan. 28, 2020 /PRNewswire/ The Center for Youth Wellness announces the release of an in-depth study on the health-related cost of adverse childhood experiences (ACEs) in the state of California . A number of studies have investigated the cost of child maltreatment, but the current study, entitled " Adult health burden and costs in California during 2013 associated with prior adverse childhood experiences ," is the first to examine the cost associated with adult health...
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Personal stories from witnesses, U.S. representatives provided an emotional wallop to House Oversight and Reform Committee hearing on childhood trauma

Room erupts in applause for the grandmother of witness William Kellibrew during July 11 House Oversight and Reform Committee hearing. The power of personal stories from witnesses and committee members fueled the July 11 hearing on childhood trauma in the House Oversight and Reform Committee* throughout the nearly four hours of often emotional and searing testimony and member questions and statements (Click here for 3:47 hour video). The hearing was organized into a two panels—testimony from...
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Promoting a Community Approach for Mental Well-Being in Our Littlest Citizens [chronicleofsocialchange.org]

Marianne Avari ·
By Andrea L. Lowe, The Chronicle of Social Change, June 10, 2019. Several years ago , my sister and I watched my 2-year-old nephew’s behavior change dramatically. He started wetting the bed, throwing temper tantrums and getting frustrated so quickly. In any other child, it might have been normal “terrible twos,” but in him we knew something was definitely wrong. At the time, my sister and her husband were getting divorced. Ultimately, we found out that my nephew thought it was his fault,...
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Teachers as Buffers Against ACEs

Kerry. Jamieson ·
We give teachers unprecedented access to our children. We entrust them to educate our children, but we also allow them to influence our children’s thoughts, attitudes, and behavior for many hours every day. Fortunately, most teachers are special, dedicated people who care deeply for the well-being of little ones. Teachers also have a profound opportunity to positively affect the life of a child with ACEs. They should be fully equipped to be the best possible buffers for our children.
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The Issue of "Other ACEs".

Kerry. Jamieson ·
Using a purist’s definition of ACEs means we only consider the original study's ten questions designed to identify incidents of abuse, neglect, and household dysfunction that might cause the kind of sustained toxic stress that defines adversity and has lifelong mental and physical health implications. However, being a trauma-informed and ACEs-aware member of society doesn't just mean knowing what ACEs are. We need to become a kind of mental detective to understand what else ACEs might be.
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Thinking About Racial Disparities in COVID-19 Impacts Through a Science-Informed, Early Childhood Lens [developingchild.harvard.edu]

By Jack P. Shonkoff and David R. Williams, Center on the Developing Child, April 27, 2020 The COVID-19 virus is ruthlessly contagious and, at the same time, highly selective. Its capacity to infect is universal, but the consequences of becoming infected are not. While there are exceptions, children are less likely to show symptoms, older adults and those with pre-existing medical conditions are the most susceptible, and communities of color in the United States are experiencing dramatically...
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This is Us - Meet Peace4Tarpon -Shannon Krukonis - P4T BOD member!

Robin Saenger ·
Shannon has over 25 years experience working with children in preschool and after school settings. Originally from Boston, Shannon holds a Bachelor's Degree in Psychology as well as an Associate’s Degree in Early Childhood Education. Since moving to Florida in 2000, she has built a career working in the early intervention field with ages 0-5, as well as working with truant teens as a case counselor in child welfare and currently as the Behavior Specialist for the YMCA of the Suncoast.
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Tools and how to use them is focus of second webinar on Community Resiliency Model, May 14, 2020

Carey Sipp ·
The second of two free Community Resiliency (CRM) webinars with Elaine Miller-Karas , key creator of the CRM, will be held Thursday, May 14, from 11 a.m. - 12:30 p.m. ET, (10 a.m. CT; 9 a.m. MT, and 8 a.m. PT) and will include the practical application of tools of the model. CRM is an ACEs science-based biological model for helping individuals become emotionally regulated during natural disasters and other dysregulating times. Miller-Karas will be joined by CRM trainers from Wilmington, NC:...
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Toxic Stress and ACEs

Kerry Jamieson (Guest) ·
Stress is a strange thing. It’s both a feeling (a sense of being under intense pressure or emotional strain) and a mechanism by which the body’s systems respond to those feelings. We hear opposing statements about stress. Either stress is good for us because it motivates us to succeed, or all the stress in our lives in going to kill us… Which one is true? When it comes to stress, it’s a matter of degree. Yes, a little stress is part of human survival. It focuses us, energizes us, and helps...
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"Turning big waves into small ripples" campaign

Sydney Little ·
My “turn big waves into small ripples” campaign focuses on creating a supportive high school culture with norms and social constructs that encourage students to cope with stressors and positively expressing their emotions. By encouraging a trauma-informed community within the school setting, students will be better prepared to cope with traumas and stressors post-graduation. They will also be capable of passing on this information to their parents, siblings, peers, and future generations.
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Upates, good news, recommendation and link to register for Making Meaningful Change: Addressing ACEs through Public Policy Webinar February 18

Mimi graham ·
The World Health Organization has compiled a recent meta-analysis about how much ACEs cost us Millions of adults across Europe and north America live with a legacy of ACEs. Their findings suggest that a 10% reduction in ACE prevalence could equate to annual savings of $105 billion. Programs to prevent ACEs and moderate their effects are available. Rebalancing expenditure towards ensuring safe and nurturing childhoods would be economically beneficial and relieve pressures on health-care...
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Webinar—Florida's Early Childhood Courts:
 Transforming Child Welfare on June 6 (3:00-4:30 ET)

Please join this June 6 webinar on Florida’s early childhood courts (aka “safe babies courts”) hosted by the National Center on Domestic Violence, Trauma & Mental Health and co-sponsored by the Campaign for Trauma-Informed Policy and Practice and ACEs Connection. Background: Every six minutes in the U.S., an infant, toddler or child under the age of 3 is removed from their homes for alleged abuse and neglect and placed in state custody through the child welfare system (Zero to Three).
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Webinar Oct. 17 — Integrating ACEs science in pediatrics: Early adopters share lessons from the field

Laurie Udesky ·
An ACEs Connection webinar co-sponsored with 4 CA In 2017, California became the first state in the country to pass a law supporting universal screening for adverse childhood experiences (ACEs) in the 5.3 million children in the state’s Medicaid program. As clinicians around California await the state’s announcement of what this new policy will entail, many are wondering what it takes to integrate ACEs science in a pediatric practice. Meet Drs. Deirdre Bernard-Pearl, R.J. Gillespie and...
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Why Is the Pandemic Killing So Many Black Americans [podcasts.apple.com]

Carey Sipp ·
By The Daily, The New York Times, May 20, 2020 Some have called the pandemic “the great equalizer.” But the coronavirus is killing black Americans at staggeringly higher rates than white Americans. Today, we explore why. Guest: Linda Villarosa, a writer for The New York Times Magazine covering racial health disparities, who spoke to Nicole Charles in New Orleans, La. about the death of her husband, Cornell Charles, known as Dickey. He was 51. For more information on today’s episode, visit...
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Yes, Stress Really is Making You Sick [newsweek.com]

By Adam Piore, Newsweek, March 2, 2020 In the mid-2000s, Dr. Nadine Burke Harris opened a children's medical clinic in the Bayview section of San Francisco, one of the city's poorest neighborhoods. She quickly began to suspect something was making many of her young patients sick. She noticed the first clues in the unusually large population of kids referred to her clinic for symptoms associated with attention deficit hyperactivity disorder—an inability to focus, impulsivity, extreme...
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12 Myths of the Science of ACEs

Jane Stevens ·
The two biggest myths about ACEs science are: MYTH #1 — That it’s just about the 10 ACEs in the ACE Study — the CDC-Kaiser Permanente Adverse Childhood Experiences Study . It’s about sooooo much more than that. MYTH #2 — And that it’s just about ACEs…adverse childhood experiences. These two myths are intertwined. The ACE Study issued the first of its 70+ publications in 1998, and for many people it was the lightning bolt, the grand “aha” moment, the unexpected doorway into a blazing new...
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ACEs Connection's Inclusion Tool makes sure nobody's left out

We developed ACEs Connection's Diversity, Equity & Inclusion Tool — called the Inclusion Tool, for short — to ensure that ACEs initiatives across the world focus on being inclusive when forming a steering committee, recruiting leaders, providing education about ACEs science, recruiting members, or providing resources and services within their communities. The more inclusive your ACEs initiative is, the more diverse it will be, giving your initiative a real shot at achieving equity and...
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Action needed today by trauma advocates to urge Congress to address mental health and trauma in current COVID-19 legislation

The follow is a message from Dan Press, Legal Advisor to the Campaign for Trauma-Informed Policy and Practice ), about the need to contact Congress regarding a COVID 19 funding bill being considered this weekend. He is urging ACEs science/trauma advocates and leaders to send emails to their U.S. Senators and Representatives immediately to address the mental health and trauma implications of this pandemic. All – I hate to bother you on a Sunday, but we urgently need you to contact Congress to...
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An Early Childhood Development Expert Explains How Trauma and Stress Can Derail a Kid’s Life [sarasotamagazine.com]

By Cooper Levey-Baker, Sarasota, December 19, 2019 Mimi Graham has spent her life fighting for kids. She began her career in the late 1970s as a Head Start administrator before moving into the world of academia to study child development and advocate for public policies that improve the health of mothers and children. Today, she’s the director of Florida State University’s Center for Prevention & Early Intervention Policy, a position in which she advises government agencies and...
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During COVID-19: The need for your skills. Self-care resources. Share your TI responses? Thank you!

Mimi graham ·
Dear Trauma F riends and C olleagues: The COVID 19 pandemic offers a critical opportunity to share your unique skills in coping with stress and trauma. Many of us and the families we serve may be shifting through the stages of change and grief----denial, anger, bargaining, acceptance---about this pandemic. You may be adjusting to telehealth and virtual visits but know that our families need your reassurance and help in regulating and coping. Hope you’re all practicing self-care while you...
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Efforts to Reduce Black Maternal Mortality Complicated by COVID-19 [chcf.org]

By Xenia Shih Bion, California Health Care Foundation, April 20, 2020 Latoyha Young had a birth plan. She was going to have the baby in Sacramento with community doula Joy Dean by her side. Dean was funded by the county’s Black Child Legacy Campaign , which works to reduce the disproportional number of Black infant and child deaths in Sacramento. But in mid-March, when Young went into labor just as Governor Gavin Newsom ordered Californians to stay at home to avoid spreading the novel...
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Fighting ACEs Amid the Pandemic

Kerry. Jamieson ·
When a pandemic hits, and suddenly nothing is the same, it’s a sobering opportunity to take a deep breath and to take stock. At Center for Child Counseling, we specialize in childhood trauma and Fighting ACEs (Adverse Childhood Experiences) and we'll keep doing what we so best...
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Governor Declares November 1, 2019 as Florida's Trauma Informed Care Day

Mimi graham ·
Thank you Governor DeSantis (and Zack Gibson in the Governor’s Office) for declaring today as Florida’s Trauma Informed Care Day . Many of Florida’s most costly, intractable social problems including our opioid and substance dependency crisis, our sky-rocketing public health costs, tragic school failures, and the multigenerational cycle of families into our criminal justice and child welfare systems, can be decreased by addressing early trauma. Initiatives are taking shape at both the state...
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How do these pediatricians do ACEs screening? Early adopters tell all.

Laurie Udesky ·
Last week, three pediatricians — with a combined experience of 15 years integrating ACEs science into their practices — reflected on the urgency they felt several years ago that prompted them to begin screening patients for childhood adversity and resilience when there was practically no guidance at all. Along their journey , they accumulated a list of lessons learned for other pediatricians and family clinics to use. The three pediatricians participated in the ACEs Connection webinar,...
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A Better Normal Tuesday, June 30th at Noon PDT: Reinterpreting American Identity, a Community Discussion

Alison Cebulla ·
"I think that all of us, regardless of our racial or ethnic background, feel relieved that we no longer have to deal with the racism and the sexism associated with the system of slavery. But we treat the history of enslavement like we treat the genocidal colonization of indigenous people in North America, as if it was not that important, or worse, as if it never happened." —Angela Davis, "The Meaning of Freedom" Please join us for the ongoing community discussion of A Better Normal, our...
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Resilience for Children & Families: Being Brave When Things are Hard

Building Resilience with Children During Racial Discrimination & Violence: This attached Resilience Brief for Children has been the hardest one I have written yet. I have been an active advocate for the equal treatment of people from all backgrounds, religions, ethnic heritages, orientations, and families my entire life. It is hard to see the pain present today, not only due to COVID19 but also due to the harm and anger we see daily in the news. I want to share a story about the person...
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Help Navigating the Road to Community Resiliency

Becky Haas ·
The first time I ever heard the words trauma-informed care and the Adverse Childhood Experiences (ACEs) study was in the summer of 2014. At the time, I was working for the local Police Department as the Director of a grant-funded Crime Reduction Project aimed at reducing drug-related and violent crime. Of the many program goals, one was to develop a rehabilitative corrections program for felony offenders with addictions in order to reduce recidivism. Though I’ve lived in this region for...
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Do safe, stable, and nurturing relationships work? New research has important findings for responding to ACEs

Alyssa Koziarski ·
While we know that adverse childhood experiences (ACEs) can cause risk behaviors, research has told us that the presence of protective factors can help mitigate the effects of ACEs. Common risk behaviors such as smoking tobacco and alcohol misuse can be a result from the trauma of childhood disadvantage. In responding to ACEs, public health research proposes that protective factors such as safe, stable, nurturing relationships (SSNRs) with a caring adult can mitigate the long-term effects of...
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Greater Richmond Trauma Informed Community Network, first to join ACEs Cooperative of Communities, shows what it means to ROCK!

Jane Stevens ·
In 2012, Greater Richmond SCAN and five other community partners hatched a one-year plan to educate the Richmond, Virginia, community about ACEs science and to embed trauma-informed practices. Eight years later, the original group has evolved into the Greater Richmond Trauma-Informed Community Network (GRTICN) with 495 people and 170 organizations. And they're just scratching the surface.
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Donald Trump is the product of abuse and neglect. His story is common, even for the powerful and wealthy.

Jane Stevens ·
“In order to cope,” writes Mary Trump, “Donald began to develop powerful but primitive defenses, marked by an increasing hostility to others and a seeming indifference to his mother’s absence and father’s neglect….In place of [his emotional needs] grew a kind of grievance and behaviors—including bullying, disrespect, and aggressiveness—that served their purpose in the moment but became more problematic over time. With appropriate care and attention, they might have been overcome.”
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Trauma-informed policing: Learn how three highly experienced community leaders strengthen ties between police and community

Carey Sipp ·
ACEs initiative participants in communities where there is tension between the community and law enforcement will want to join Becky Haas in a compelling conversation on law enforcement, ACEs science, COVID-19 and the Black Lives Matter movement and protests. Haas is a nationally recognized adverse childhood experiences (ACEs) science initiative builder and trainer. She and colleagues Renee Wilson-Simmons, the head of the ACE Awareness Foundation of Memphis, Tennessee, and Maggi Duncan,...
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Baby courts: A proven approach to stop the multigenerational transmission of ACES in child welfare; new efforts to establish courts nationwide

Carey Sipp ·
The organization Zero To Three estimates that in the U.S., a child is taken into the child welfare system every six seconds. “Many of society’s most intractable problems can be traced back to childhood adversity. Being in the child welfare system increases the likelihood of more adversity and criminality. Baby court is a proven approach to healing the trauma of both child and parent, and breaking the cycle of maltreatment,” says Mimi Graham, Ed.D ., director of the Florida State University...
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Does VP Candidate Kamala Harris know about ACEs?  You bet!

Nadine Burke Harris, California’s Surgeon General, has a lot in common with the vice presidential candidate Kamala Harris—Jamaican heritage, surname, home state—and a commitment to addressing ACEs and toxic stress. As reported in the New Yorker article by Paul Tough, “The Poverty Clinic,” Dr. Harris told Kamala Harris, then San Francisco district attorney, about ACEs in 2008 and in response, she offered to help. District Attorney Harris then introduced her to professor of child and...
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FSU launches new level of professional certification on trauma and resilience (Florida State University News)

Karen Clemmer ·
By Anna Printess, August 31, 2020, Florida State University News. Florida State University’s College of Social Work recently launched a new level in its successful Professional Certification in Trauma and Resilience online series. The curriculum series, developed by the Clearinghouse on Trauma and Resilience within the college’s Institute for Family Violence Studies in conjunction with the FSU Center for Academic and Professional Development , enables professionals to develop the knowledge...
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The Intersection of Systematic Racism, the Pandemic, and SDoMH: Reality Mandates Change

Ellen Fink-Samnick ·
Systematic racism is at the core of mental health disparities and social determinants of mental health (SDoMH).Upstream factors obstruct patient access to needed and appropriate assessment, timely intervention, with treatment for these populations often reflecting poorer quality, and ending prior to completion of treatment. COVID-19 and the recent pandemic have only amplified meso and micro-level gaps in care. considered, provided, and reimbursed.
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"A Better Normal" Community Discussion: Suicide Awareness and Community Cafes

Karen Clemmer ·
Join us on Friday November 6, 2020 from noon to 1:00 PST as we come together and join Satya Chandragiri MD, Bonnie O’Hern RN, Denise Proudfoot RN, & Michael Polacek RN for a discussion around the tender issue of suicide. Together we will discuss ways people and providers can support each other and encourage communities to take action to support one another around suicide prevention, crisis intervention, and the layers of culture and structural barriers to care. A special emphasis will be...
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Opportunity to sign on to “A Trauma-Informed Agenda for the First 100 Days of the Biden-Harris Administration”—Deadline Dec. 8th

The Campaign for Trauma-Informed Policy and Practice ( CTIPP ) is inviting individuals and organizations to express their support for a set of executive actions for the Biden-Harris Administration to take “to address trauma and build resilience throughout the country.” Most of these actions could be taken early in the Administration and would not require congressional action with the exception of some recommendations that could be included in a new stimulus package. The recommendations are...
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Committed: How a 6-Year-Old Revealed Florida's Dysfunctional System of Baker Acting Kids [centerforhealthjournalism.org]

By JacqueLynn Hatter, Center for Health Journalism, December 13, 2020 The number of children who are taken for involuntary psychiatric evaluations in Florida increases every year. This is the first story in a five-part series about how the state's Baker Act affects children. Each day in Florida, about 100 kids are involuntarily committed for psychiatric exams under the state's Baker Act. The law was not designed for children, yet over the past few years, the number of minors taken for mental...
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ACEs Connection/CTIPP Southeastern Leaders’ call: State updates, funding information, and “mind-blowing” information about helping people out of poverty

Carey Sipp ·
Southeastern ACEs Connection and national CTIPP leaders on the quarterly leader call welcomed guest speaker Rebecca Lewis-Pankratz (top left) for their quarterly call. Also among those present were (top row l-r) Carey Sipp, Jesse Kohler, Jesse Hardin, (second row, l-r) Patti Tiberi, Mebane Boyd, Jen Drake-Croft, Dan Press, (third row, l-r) Mimi Graham, Christopher Freeze, Margaret Stagmeier, (fourth row, l-r) Emily Marsh, Liz Peterson, Alyssa Koziarski and Janet Pozmantier. Also present was...
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Moving from Global Trauma to Hope

Kerry. Jamieson ·
Wednesday, January 20, 2021 was the start of a new era in American politics. Joseph Biden was inaugurated as the 46th president of the United States. It ushered in a dramatic change in terms of leadership, but also represented the end of a four-year period of turmoil in the lives of everyday people, marked by division, dissent, violence, hatred, self-serving policies, incivility, nepotism, and greed. President Biden acknowledged the extraordinary times in which we live during his inaugural...
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Join Special Guest Father Paul Abernathy for a Zoom Discussion on March 16th, at 7p.m. EST to discuss the Whole People Documentary Series and Trauma-Informed Community Development

Christine Cissy White ·
On behalf of ACEs Connection , the CTIPP (The Campaign for Trauma -Informed Policy & Practice), and the Relentless School Nurse , we want to invite you to the streaming of parts 4 and 5 of the Whole People documentary series on the weekend o f M arch 12th through March 14th, 2021. We will stream both parts on ACEs Connection in the Transforming Trauma with ACEs Sciences Film Festival community. The documentary viewing will be followed by a discussion with special guest, Father Paul...
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A Better Normal Friday, March 26, 2021: PACEs and HOPE with Dr. Christina Bethell

Jane Stevens ·
Please join us for our next installment of A Better Normal, our live webinar series in which we imagine and create our society as trauma-informed! You may have seen we changed our name recently from ACEs Connection to PACEs Connection. Please join us to learn all about the groundbreaking research of Positive Childhood Experiences and how this is going to transform the work we are all doing. >>Click here to register<< PACEs and HOPE Live Event Friday, March 26, 2021 Noon PT / 1pm...
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Spreading HOPE Summit – Afternoon Session Feature, Pt. 5: Jane Stevens and Dr. David Willis [positiveexperience.org/blog]

Chloe Yang ·
Chloe Yang, 3/29/21, positiveexperience.org/blog Our first annual summit is less than a month away! Please register at this link , which you can also find on the Summit landing page (registration closes at 5:00 pm ET on Monday, April 5th). Our virtual summit seeks to inspire a group of leaders who will, together, champion a movement to shift how we support children and families, creating systems of care based on understanding, equity, and trust. Morning plenary sessions will feature Dr. Bob...
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Register now! Best-Selling Author, Best Trauma-Informed Practices -- Including Handle With Care, Safe Baby Courts -- Highlight Packed Third Annual "Creating A Resilient Community" Conference!

Britney Pierce ·
“The agenda for the third annual “Creating a Resilient Community Conference (Virtual Event)” reads like an all-star cast of trauma-informed experts coming together to share the best of what they know, and offers myriad opportunities for communities at all stages of becoming trauma-informed to learn about best practices, in many instances, by people who created landmark trauma-informed programs,” said Rachel C. Allen, PJI Director. The two-day conference, which starts April 20th, features...
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Best Practices, Internationally Respected Experts Featured at ACEs Central Florida Conference. Registration Closes Monday!

Rachel C. Allen ·
Donna Jackson Nakazawa ( photo by Marshall Clarke ), award winning science journalist and author of Angel and the Assassin , will join Dr. Mimi Graham , director of Florida State University's Center for Prevention and Early Intervention Policy , Andrea Darr , creator of Handle With Care, Captain Lovetta Quinn-Henry , from the Orlando Police Department and many more featured at the conference. Help your community move the needle toward a trauma-informed, resilient community by learning from...
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Child Care Relief Funding in American Rescue Plan: State-by-State Estimates [CLASP]

March 10,2021 Editor’s note: This article includes CLASP estimates on child care relief funding each state, D.C., and Puerto Rico will receive of the $39 billion included in the American Rescue Plan Act (ARP Act) For decades, our country has had a child care crisis fraught with inequitable access for communities of color, unaffordable care for far too many families, poverty-level wages for early educators, and razorthin margins for providers. This long-term crisis has been exacerbated by the...
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