It's been over a month since the third Essentials for Childhood Summit on November 29th, 2018 and I can't stop thinking about remarks from the keynote speaker, Dr. Melissa Merrick, Ph.D. who is a Senior Epidemiologist at the National Center for Injury Prevention and Control in the Division of Violence Prevention, Centers for Disease Control and Prevention.
Merrick, who recently published findings from the largest ACEs study to date, spoke about ACEs, the Essentials for Childhood framing to create safe, stable, nurturing relationships and environments for all children, and how we can all work together to promote health, health equity, and well-being for kids, families, and communities.
Merrick answered questions from Dr. Robert Sege, who is on the leadership team of MA Essentials for Childhood and is Director of Stakeholder and Community Engagement at Tufts Clinical and Translational Science Institution and had a great conversation with summit attendees. Please find select quotes, notes and slides below (slides are also attached).
ACEs & Safe, Stable & Nurturing Relationships & Environments
"I think this is a critically important public health topic. If we have healthier kids, we will have healthier adults. I mean its pretty simple in that respect. I'm trained as a child psychologist so yes, I'm a child person. But we can't just care about kids and not care about their parents. And we can't care about parents and families without thinking about the community, and we can't think about the community without recognizing that the community exists within a sociopolitical context. So I think this move to assuring the conditions for health and well-being, to be honest, that's the basic tenet of public health in general, to really assure the conditions where everyone can be healthy and thrive. So it's in that spirit that we really do the work that we're doing."
Dr. Melissa Merrick
Dr. Merrick talked about the prevalence of ACEs and their impact on "chronic disease, mental health outcomes, physical health outcomes, these behaviors, things like substance use, etc. and life potential outcomes - being employed, finishing high school, and not living in poverty - things that are protective and good for our health," she said.
Poor outcomes and risks, from ACEs she said, "These things happen, in the absence of protective factors," adding, "ACEs are by no means are deterministic. It does not mean if your ACE score is off the charts you will get... insert health outcome here... it just means that your risk is much higher especially in the absence of these positive experiences."
"I'm less interested in documenting the 41st, 43rd health outcome associated with early adversity. I think this research is really robust, as many of you know. I think now we're in the business of preventing it in the first place. I think how we do that is through multi-generational approaches that assure the conditions for health and well-being through safe, stable and nurturing relationships and environments for all children."
Dr. Melissa Merrick
Dr. Merrick stressed how addressing the root causes such as "poverty, discrimination, all the isms...." are important to "to getting at the context," in which ACEs occur.
She reminded us how real and present early adversity is for children and that "11,500 kids die, because of violence, every week and a half, around the globe," she said.
"It's a simple sum, right. So, the more you have, the higher your number is, it does not get into things like severity, the age of onset, how old you were in development, who the perpetrator was, other types of contextual factors that would also impact these outcomes. There's some beauty in the simplicity..... but it's important to acknowledge what's not included. What's not measured? We know this isn't the entire universe of adversity that our kids or kids around the world are experiencing (peer bullying, witnessing violence in the community or school, homelessness, poverty, even what's happening at our borders)."
She spoke about the need to also address conditions, contexts, and root causes, what she said Wendy Ellis calls adverse community environments in her Pair of ACEs work.
"We need primary prevention efforts and trauma-informed systems and responses. Think about it. If we really take a multi-generational approach to prevention, we can recognize parents history of adversity and treat and come in with trauma-informed services and that, is in fact, primary prevention strategy for kids." Dr. Melissa Merrick
While noting that all kids need safe, stable, nurturing environments and that the presence or absence of adversity and protective factors impact developing brains and bodies, she also recognized that some kids face more adversity and have less protective factors than others. "However, what this is not to meant to suggest is that we're trying to disappear the groups of kids that we knew experience a disproportionate amount of the burden of early adverse experiences," she said.
“Really, we’re trying to achieve a healthy and equitable society.” Dr. Melissa Merrick
Discussion: Dr. Melissa Merrick, Dr. Robert Sege & Summit Attendees
The discussion between Dr. Merrick and Dr. Sege (photo below, right) as well as the rest of the audience was terrific.
Dr. Sege had reviewed the Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States and asked Dr. Merrick questions about how our statewide collective impact team might make use of the data to support our work in Massachusetts which will have a stronger and sharper racial equity focus going forward.
Dr. Sege asked about differences in the amount as well as types of ACEs reported, for example, how to make sense of the fact blacks reported higher ACE scores, overall, and fewer abuse-related ACEs than whites. His questions led to more discussions, questions, and considerations and he and Dr. Merrick discussed how and why data collected by adults, retrospectively, differs from data coming from abuse and neglect reports made about children and families in real time; the role of racial bias in those reporting possible abuse; how under-reported ACEs are; and what part racial bias played in responses to the original ACEs study which was done mostly on middle-class, white, employed, insured, and educated adults - among other things!
I wished we'd had more time to unpack and digest it all. At times, I felt overwhelmed by questions, concerns, and sometimes seemingly contradictory information. But Dr. Sege was upbeat and hopeful, and Dr. Merrick was calm, clear, and consistent.
She repeatedly returned to one message - the need for creating safe, stable and nurturing relationships and environments for children, families, and communities.
"Understanding adversities that parents today are reporting give us again this information on the conditions or the context in which children are being raised....," she said, because we know, "if parents have a history of early adversity their kids are likely to have a history of early adversity."
She said that though we know that ACEs are not "the entire universe of early adversity," they do tell us quite a bit. We know that "8 out of 10 leading causes of death have roots in early childhood. When you look it at that, everyone in a medical context should care about this information and should want to talk about this information, but we know we're not quite there yet," she said.
The "end goal" is clear, Dr. Merrick said, is clear, to "assure the conditions," which create safe, stable, nurturing relationships and environments for children and all families and communities. She reminded us what the recent ACEs study shows, how common ACEs are and that ACEs disproportionately impact some groups. A summary of the study findings, in her own words, is below (from an interview with Medical Research):
"This study found that Adverse childhood experiences are common, with approximately two thirds of respondents reporting at least one ACE. People who identified as black, Hispanic, or multiracial, identify as gay, lesbian, or bisexual, less than a high school education, unemployed or unable to work, and an annual income of less than $15,000 were at a significantly higher risk of ACE exposure. Additionally, the study found that the most common ACEs were emotional abuse, parental separation or divorce, and household substance abuse."
At the summit, she said, about those disproportionately impacted by ACEs "it's not because there's something wrong with them but because of the historical, the structural, the social determinants of health" which she noted, "also occur across generations."
She said, "from a public health approach if we're really talking about building the polices the political will, the socioeconomic conditions, the structural supports for health and well being. I do think in that space our end game is pretty much the same."
Towards that endgame, Dr. Merrick mentioned the CDC's technical package on preventing child abuse and neglect which is available to assist anyone, (including our collective impact team) wondering how best to protect and care for children, families, and each other.
Sources:
- Keynote Presentation and slides by Dr. Melissa Merrick presented at Massachusetts Essentials for Childhood Summit, Nov., 2018
- Q&A discussion between Dr. Melissa Merrick, Dr. Robert Sege, and audience members following keynote at Massachusetts Essentials for Childhood Summit, Nov. 2018.
- JAMA Pediatr. 2018;172(11):1038-1044, November 2018, Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States, Melissa T. Merrick, PhD1; Derek C. Ford, PhD1; Katie A. Ports, PhD1; et alAngie S. Guinn, MPH1
- CDC Identifies Risk Factors for Adverse Childhood Experiences, MedicialResearch.com, September 17, 2018
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