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Healthy Charlotte County ACEs Connection (FL)

Our vision for a healthy Charlotte County is a safe, equitable and vibrant community in which people feel empowered to seek and obtain opportunities and services to achieve and maintain a high quality of life.

Tagged With "trauma informed care"

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Blog Post

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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A Florida ACEs Tour

James Encinas ·
RADICAL GRACE – WHAT I LET GOD SEE AND ACCEPT IN ME ALSO BECOMES WHAT I CAN SEE AND ACCEPT IN MYSELF. AND EVEN MORE, IT BECOMES THAT WHEREBY I SEE EVERYTHING ELSE. ~ RICHARD ROHR For the past three months, I’ve been driving through various parts of Florida witnessing events and gatherings of communities committed to creating safe, loving, trauma informed, and trauma healing spaces. On Friday February 22nd, I was in Tarpon Springs, attending the monthly gathering of Robin Saeger’s...
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ACEs & African Americans Community on ACEs Connection

Ingrid Cockhren ·
ACEs Connection envisions a resilient world where ALL people thrive. We are an anti-racist organization committed to the pursuit of social justice. In our work to promote resilience and prevent and mitigate ACEs, we intentionally embrace and uplift people who have historically not had a seat at the table. ACEs Connection celebrates the voices and tells the stories of people who have been barred from decision-making and who have shouldered the burden of systemic and economic oppression as the...
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ACEs Connection Central Florida Launches at First Annual Conference

Carey Sipp ·
Photo by James Encinas Raising yellow “Visions & Commitments” cards, 550 attendees at yesterday’s Creating a Resilient Community: From Trauma to Healing Conference pledged their enthusiastic support to create a more resilient Central Florida. The standing-room-only crowd heard Dr. Vincent Felitti deliver a morning keynote address detailing the findings of the CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) . He also shared moving testimonials of people who are...
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ACEs Connection's Inclusion Tool makes sure nobody's left out

Ingrid Cockhren ·
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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Beyond ACES Summit: The Impact of Race, Culture, and Poverty Social Media Toolkit

Brian Little, CHD ·
The Beyond ACES Summit: The Impact of Race, Culture, and Poverty registration is LIVE! The summit theme is #MovingBeyondACES (adverse childhood experiences). This year is historically significant because it marks the 400th anniversary of the arrival of enslaved Africans to Virginia. It was also a time that marked significant trauma. The summit touches on many different aspects of life and history. It was showcase the heartfelt talent of youth through dance and movement, music, theatre and...
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Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic [jamanetwork.com]

By Abby R. Rosenberg, JAMA Pediatrics, April 14, 2020 Coronavirus disease 2019 (COVID-19) is affecting our health care community in unprecedented ways. As a pediatric oncologist who studies resilience in the context of illness, I started thinking about what this pandemic means for our professional resilience a few weeks ago, when the first US patient with fatal COVID-19 died in my home city of Seattle, Washington. Promoting resilience among health care workers and organizations starts with...
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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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Florida Governor's Wife announces mental health aid for Panhandle after Hurricane Michael

Bob Doppelt ·
Photo credit: Florida's Governor's Office The story below illustrates the urgent need to proactively build psychological and psycho-social-spiritual--Transformational Resilience--for climate change related disasters. It describes how the mental health impacts of these disasters often becomes most acute months after a disaster occurs, which is long after mental health first aid and other disaster mental health services have ended. Prevention is the only solution, and the focus must be on...
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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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Hurricane Dorian’s on the way. Florence taught us how to be resilient!

Mebane Boyd ·
As we prepare for the arrival of Hurricane Dorian's effects later this week, certainly there are feelings of anxiety and confusion. Already? We haven't even finished recovering from Hurricane Florence! Let's choose to remember all the things we have learned from one another about being resilient in the face of stress over the course of the past year. We have learned about the body's response to stress and trauma, and that adding "stressors" and triggers to these can cause us to feel even...
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Introducing the 5 Newest ACEs Connection Communities (February, 2019)

Christine Cissy White ·
Please welcome and explore the five newest communities to join our network in Alabama, Florida, Kentucky, New Jersey, and North Carolina. 4 New Communities Join ACEs Connection! BOUNCE - Jefferson County (KY) Edgecombe County (NC) ACEs Connection First 5 Alabama ACEs Connection Healthy Charlotte County (FL) ACEs Connection Newark (NJ) Trauma-Informed Community Network Please find more details about each one of them below. Follow links for a list of all of our ACEs Connection communities or...
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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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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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Nine Simple Trauma-Informed Gestures for Educators

Eric Rossen, PhD, NCSP ·
The promotion of trauma-sensitive and trauma-informed schools has grown tremendously in education. Broadly speaking, trauma-informed schools maintain a framework whereby the entire school staff maintains awareness of the impacts of toxic stress and trauma, and strive to ensure that all students feel safe, supported, and connected. Such awareness and motivation among educators and caregivers to promote such a framework presents multiple opportunities to change the lives of students and help...
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Nurturing relationships in childhood boost adult mental health, relationships

Christina Bethell ·
We're proud to announce major research that suggests that positive childhood experiences — such as supportive family interactions, caring relationships with friends, and connections in the community — are associated with reductions in chances of adult depression and poor mental health, and increases in the chances of having healthy relationships in adulthood. This association was true even among those with a history of adverse childhood experiences.
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One state. One year. (Partial) Cost of ACEs = $5.2 billion.

Jane Stevens ·
In looking at the impact of childhood trauma, you can’t get much clearer than this: In 2017, ACEs among Tennessee adults led to an estimated $5.2 billion in direct medical costs and lost productivity from employees missing work. That’s just one year, according to the new report, “ The Economic Cost of ACEs in Tennessee ," released on Feb. 1, 2019 by The Sycamore Institute in Nashville, Tenn. And to provide some perspective, $5.2 billion is one-seventh of the state’s annual budget . This $5.2...
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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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Recording and slides now available for webinar on Florida’s Early Childhood Courts: Transforming Child Welfare

Information (recording, slides, and resources) on the June 6 webinar "Florida’s Early Childhood Courts: Transforming Child Welfare" is now available (and soon to posted in the ACEs Connection webinar section on the homepage). This well-attended and received webinar was sponsored by the National Center on Domestic Violence, Trauma & Mental Health and co-sponsored ACEs Connection and the Campaign for Trauma-Informed Policy and Practice ( CTIPP ) Webinar Summary Every six minutes in the...
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Sheltering in Place: ACEs-Informed Tips for Self-Care During a Pandemic

Jim Hickman ·
Millions of lives have been affected in unprecedented ways by the Coronavirus (COVID-19). We are all grappling with uncertainty—our daily routines interrupted, not knowing what is to come. For those of us who have Adverse Childhood Experiences (ACEs), these times can be particularly distressing. At the Center for Youth Wellness (CYW), we know that childhood trauma can have a significant impact on an individual’s health and well-being – both physiologically and psychologically. Since the...
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Webinar: Cultivating Our Best Selves in Response to COVID-19 | Tuesday, March 17 at Noon PDT

Elaine Miller Karas ·
How to use the skills of the Community Resiliency Model (CRM) for self and others to be the calm in the storm as we face the unknown. Free Webinar Tuesday, March 17 at Noon PDT Speakers: Elaine Miller-Karas, LCSW Linda Grabbe, PhD, FNP-BC, PMHNP-BC Zoom Webinar Registration Link: https://zoom.us/j/715837300 Additional ways to join are listed at the bottom of this post. About the webinar leaders: Elaine Miller-Karas is the Executive Director and co-founder of the Trauma Resource Institute and...
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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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When the Cross is On the Table

Robin Saenger ·
Susan Traylor says “When they see the cross on the table, they know someone has died.” The ‘they’ she is talking about are the many folks experiencing homelessness in our small community of Tarpon Springs, Florida. A few weeks ago, the cross was on the table for Terry. I knew him by sight but never knew his name. I observed him over the past few years quite often in a state that makes most people not only uncomfortable, but anxious and fearful as he argued with someone only he could see. He...
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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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Your daughters, sisters, mothers escaping jail's revolving door

Jennifer Sexton ·
“You didn’t wake up at 14 years old and stick a needle in your arm,” she tells them. “Nobody does that. You did it for a reason, and you might not even realize what that reason is.”
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The Black Community, COVID-19 & Trauma [sdvoice.com]

By Latanya West, San Diego Voice, May 15, 2020 In January 2019, Governor Gavin Newsom appointed Dr. Nadine Burke Harris as California’s first-ever Surgeon General. An award-winning physician, researcher and advocate, Dr. Burke Harris’ career has been dedicated to serving vulnerable communities and combating the root causes of health disparities. Her work is equally dedicated to changing the way our society responds to one of the most serious, expensive and widespread public health crises of...
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THE BUILD HEALTH CHALLENGE 2019 CALL FOR APPLICATIONS

Karen Clemmer ·
To read the announcement and all details, click HERE and see below key dates. BUILD is looking to support dynamic collaboratives driving sustainable improvements in community health. Are you ready to BUILD with us? For this new third cohort, BUILD is looking to support up to 17 innovative collaboratives across the US t hat include a community-based organization, hospital or health system, and public health department working together in dynamic ways to address upstream challenges and drive...
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The unseen hand in Charlotte health care

Jennifer Sexton ·
Sexton is the voice of the Health Department By RUSTY PRAY SUN CORRESPONDENT Jennifer Sexton is the unseen hand at work in Charlotte County health care. You may not know her name, but you’ve heard her voice. She is the public information officer of the Florida Department of Health in Charlotte County. She’s the one who lets media outlets know about everything from the local status of the Zika virus to car-seat classes for parents of young children. She has another job, one that is outside...
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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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Trauma-Informed Care Training at Charlotte High School

Jennifer Sexton ·
Staff from Charlotte High School invited trainers from SEDNET to bring Trauma-Informed Care curriculum to Punta Gorda, Florida. The training was held on November 6, 2018, adding to the growing number of education staff in Charlotte County that are well-versed in the impacts of childhood adversity, as well as preferred approaches for working with students who exhibit signs that they may have experienced trauma.
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Trauma is Messy

Jon Eppley ·
I will always remember the day that, as a student teacher, I watched as a student entered my second-grade room covered in blood. After quickly establishing that he was not injured, we learned that the blood was that of his brother who had been shot the night before. No parents were around that night, so this second grader became the sole caregiver of his bleeding brother. My student would never be the same. We didn’t care about grades or test scores. We just knew that this moment would...
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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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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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'A Better Normal' Community Discussion Series: How to Grow a Resilient Community - July 7, 2020

Interested in learning what it takes to Grow a Resilient Community? Do you want to learn how to become a member of ACEs Connection Cooperative of Communities? If so, please join us Tuesday, July 7th, 12-1pm PDT for our next 'A Better Normal' community discussion series. In this discussion we will be talking with Brian Semsem of Fresno's Every Neighborhood Partnership. We will be talking to Brian about what led him to work with ACEs and resilience. In addition, we will be discussing the path...
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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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‘Death by structural poverty’: US south struggles against Covid-19 [theguardian.com]

Carey Sipp ·
Monica McCasklill, left, and her daughter Kena Johnson, at their home in Greenwood, Missisppi. They respectively lost their grandmother and great grandmother, Ethel Huntley, to Covid-19. Huntley lived in a nearby nursing home and the family allege failings in her primary care. Photograph: Rory Doyle/The Guardian. By Oliver Laughland, The Guardian, August 5, 2020 Poor access to healthcare, failed political leadership and the endurance of segregation and racism have contributed to a surge in...
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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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New ACEs initiatives learn about strategic plan development from from New Hanover (NC) Resiliency Task Force executive director Mebane Boyd

Carey Sipp ·
The desire to see other ACEs initiatives grow and flourish was evident at a recent meeting of the Resilient Columbus County (North Carolina) ACEs initiative when Mebane Boyd, executive director of the New Hanover Resiliency Task Force (also in North Carolina), shared with the Columbus County and neighboring Pender County groups how New Hanover created and works on its strategic plan. In the spirit of sharing, Boyd agreed to let ACEs Connection post the strategic plan and the video of the...
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Charlotte County, Florida receives ACEs Proclamation!

Rebecca Francois ·
Good evening, On Tuesday September 22, 2020 (tomorrow), the Charlotte County Board of County Commissioners will sign a proclamation recognizing October as Adverse Childhood Experiences Awareness and Action Month in Charlotte County, FL . The Healthy Charlotte Community Connection Taskforce has worked hard to see this proclamation signed and recognized by our county since the beginning of 2020 and are extremely grateful for the opportunity to raise public awareness on one of the most...
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ACEs Proclamation in Charlotte County, FL

Rebecca Francois ·
Good morning! I am pleased to announce that the Charlotte County Board of County Commissioners signed an ACEs proclamation on Monday, September 22, 2020 recognizing the month of October 2020 as Adverse Childhood Experiences Action and Awareness Month. The Healthy Charlotte Community Connection Taskforce worked hard to see this come into fruition. The initial goal was to have a proclamation declared for the month of September because it is trauma-informed care month, however, our local BCC...
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Hope and Progress, No Matter What! — an ACEs Connection/Cambia Health Foundation “Better Normal”, Oct. 22, 2020

Jane Stevens ·
The election is upon us. In two short weeks, we voters in this country decide who will lead us for the next four years. We have the opportunity to embrace — as a national priority — the tenets of understanding, nurturing and healing that underlie the science of adverse childhood experiences and move in a direction that embraces cultural and racial equity and anti-racism. Or not. What is clear is that no matter what, the ACEs movement will continue.
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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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