Nicole Daley (left), Director, Division of Violence and Injury Prevention, Massachusetts Department of Public Health (MDPH) and Lauren Cardoso, Epidemiologist, Child & Youth Violence Prevention, MDPH
Nicole Daley and Lauren Cardoso were just a few months into their new positions with the Massachusetts Department of Public Health (MDPH) when COVID-19 and racial reckoning swept across the United States, creating both challenge and opportunity in their work.
In this new environment, Daley who is the Director of MDHP’s Division of Violence and Injury Prevention, became the Principal Investigator for the CDC Preventing ACEs: Data to Action (PACE-Data2A) grant program. Massachusetts and three other states—Michigan, Georgia, and Connecticut—were awarded $500,000 annually for three years. The grants were announced by CDC on August 25. A one-page abstract of the Massachusetts proposal and logic model are attached.
Early in her tenure at MDPH, Daley was involved in the Association of State and Territorial Health Organization’s (ASTHO) ACE capacity assessment tool initiative—a project that added to the department’s awareness of the impact of ACEs, according to Daley. Cardoso, who is an epidemiologist in MDPH’s Child & Youth Violence Prevention division,was developing a COVID impact survey in the state and realized how the CDC grant’s emphasis on data surveillance could complement and inform that work.
Scope of the project
CDC grantees must meet the following requirements in three major areas of work:
—enhance or build the infrastructure for the state-representative collection, analysis, and application of ACE-related surveillance data that can be used to inform and tailor ACE prevention activities;
—implement strategies based on the best available evidence to prevent ACEs; and
—conduct data to action activities to continue to assess state-wide surveillance and primary prevention needs and make needed modifications.
Positive Childhood Experiences
The development of an ACEs-related surveillance system for Massachusetts will utilize the existing Youth Risk Behavioral Survey (YRBS) and Youth Health Survey (YHS), surveying the same population with new questions about positive childhood experiences (PCEs). Daley says the aim is to examine how to capture the burden of ACEs and at the same time, elevate PCEs.
MDPH is working with the state’s Department of Elementary and Secondary Education (DESE) that is responsible for the administration of the YRBS (MDPH is responsible for the YHS). Daley says DESE, in a sign of commitment, seeks to understand what is happening with youth at a population level and planned to include an ACEs module in an upcoming survey, even if the state had not received the CDC grant. She also says that screening for ACEs at the individual level is not being considered at this time. However, the inclusion of questions related to experiences such as discrimination based on race and/or sexual orientation—beyond the original 10 ACEs in the 1998 study—is being considered.
At the end of 2019, Massachusetts was one of eight states that had not included the ACEs module in the Behavioral Risk Factor Surveillance Survey (BRFSS.) This is the first year that data is being collected, and “should provide valuable context for youth-focused surveys,” according to Daley. The BRFSS is a retrospective survey, asking adults about their experiences in childhood while the YRBS and YHS are asking mostly young people about current experiences and histories. The CDC grant emphasizes the importance of gathering contemporaneous data from young people.
CDC requires the state to do an annual state profile at the end of each of the three years of the grant cycle. The first cycle of the grant ends August 31, 2021. Annual profiles from the four grantee states should provide valuable information about ACEs prevalence and impact in those states as well as provide a template for other states to consider.
One of the program’s partners is the Hope (Health Outcomes from Positive Experiences) Center, led by Robert Sege, MD, PhD of the Tufts University School of Medicine. Daley says the Hope Project is helping with work around PCEs and developing trainings and technical assistance as part of the grant. The Hope Center and ACEs Connection recently conducted a survey of ACEs Connection members on PCEs and reported those results on the HOPE Center community site (Balancing ACEs with Hope) on ACEs Connection. MDPH in its partnership with HOPE adopted several measures into the YHS to capture the prevalence of PCEs among middle school and high school youth.
Strategies to Address ACEs and Promote PCEs
The second task of implementing evidence-based strategies is taking shape in Massachusetts. The grant announcement said: “Recipients will focus on the implementation of at least two designated strategies derived from CDC’s Division of Violence Prevention’s (DVP) resource, Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. In these endeavors, recipients will be expected to leverage multi-sector partnerships and resources in order to improve ACEs surveillance infrastructures and to coordinate and implement ACEs prevention strategies. As a result, recipients will better understand the burden of ACEs in their communities and engage in strategies that will prevent ACES from occurring, in order to help to promote safe, stable, nurturing relationships and environments where children live, learn and play.” The “Preventing ACEs” document was released in 2019 by the Division of Violence Prevention, National Center for Injury Prevention and Control.
The Preventing ACEs document outlines six major strategies from which awardees are to choose at least two. They include strengthening economic supports to families and promoting social norms that protect against violence and adversity. Daley says “paid family medical leave” will be one of the two strategies selected to collect data about the impact of this strategy to prevent ACEs. Daley says that Massachusetts has undertaken the implementation of a paid family medical leave (PFML) program that will begin dispersal on January 1, 2021. She says the program will be phased in starting with individuals with serious medical conditions and caring for family members with a serious medical condition related to military service. In July 2021, the benefit will expand to include caring for family members with serious medical conditions, e.g., individuals who have been impacted by ACEs, such as substance abuse.
Another strategy included in the grant planning process is to develop ACEs prevention and PCEs community toolkits with resources, training modules, etc. This strategy includes a desired outcome to “increase the number of communities that employ PCEs promotion strategies to engage men and boys in ACE prevention,” using the resource tools in Preventing ACEs document. See attached Massachusetts Logic Model —PACE-D2A.
Daley also reported on the efforts to partner with the state’s Youth Violence Prevention program and about 60 organizations and providers across the state, saying there is interest “supporting the professional development and skills of providers so that when a young person is experiencing the impact of ACEs (e.g., suicidality), they are able to help mitigate the impact.”
Daley and others recognize that there are innovative and effective trauma-related programs throughout the state but that the work is often siloed and done without mutually beneficial linkages among organizations and programs. The ongoing work of the MDPH, including the COVID impact survey, and grant-related work such as the development of a data dashboard, will give these now siloed programs a shared understanding of ACEs prevalence, and other stressors on communities and families across the state.
Massachusetts Essentials for Childhood
Daley says the grant was written in conjunction with the state’s Essentials for Childhood program that prioritizes economic security for families. She says the grant will try to leverage, not duplicate, the work of Essentials as well as expand it.
Cardoso expressed excitement about looking at both ACEs and PCEs, highlighting “how do you prevent those adverse experiences, and how do you facilitate the positive ones that we know have such an important impact in people's lives?” Additional questions will be considered related to racial and gender discrimination, immigration and COVID-related experiences. Cardoso also said COVID presents data collection challenges—one example being that the YHS survey is administered in schools and there is no certainty that children will be in school this academic year to participate. A second example is understanding changes in the data that may be directed related to COVID creating “an anomaly of a year or two” changing the trend data that may be very hard to understand, according to Cardoso.
There is a strong commitment from the executive office to address the needs of the most vulnerable people in the Commonwealth and examine how to elevate and support communities, especially those disproportionately impacted by ACEs, according to Daley. This includes the work around race and health equity by Governor Charlie Baker and the leadership of the Department of Health and Human Services. Massachusetts First Lady, Lauren Baker, is an active child advocate and chaired the National Governors’ Association Spouses program in 2017-2018 that focused on ACEs and trauma-informed care.
Congressional genesis of project
Derrick Gervin, PhD, Team Lead for PACE-D2A project, said on a May 14 webinar that his division had to fast track this program, learning of congressional action in December, 2019 and issuing a Notice of Funding Opportunity (NOFO) in four months, an unusually short period for the development of such a project. The FY ’20 Appropriations law includes “funding to inform how adverse childhood experiences increase the risk of future substance use disorders, suicide, mental health conditions, and other chronic illnesses as authorized in section 7131 of the SUPPORT Act (P.L. 115–271).” The SUPPORT Act, “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act,'' is the bill signed by President Trump on 10/24/2018 in response to the opioid crisis.
How the project defines ACEs
The NOFO says that ACEs “are preventable traumatic events that occur in childhood (0-17 years)” and include such things as neglect and witnessing violence and also include ”aspects of children’s environment that undermine their sense of safety, stability, and bonding such as growing up in a household with substance misuse.” It notes the importance of surveillance to understand the scope of the problem, where ACEs are most likely to occur, and who is at greatest risk. It identifies a deficit in surveillance for youth and adolescents, noting that the Behavioral Risk Factor Surveillance System (BRFSS) assesses ACEs retrospectively among adults.
In the 20+ years since the publication of the CDC-Kaiser Permanente Adverse Childhood Experiences Study, the CDC, the nation’s premier public health agency, as added to the growing momentum around the acceptance and implementation of ACEs science on several fronts. It has supported the inclusion of the ACEs module in the BRFSS in nearly every state. It issued the ACEs Vital Signs report in late 2019 that provides the first U.S. estimates of how preventing Adverse Childhood Experiences (including child maltreatment) and associated trauma has the potential to reduce chronic diseases, risky health behavior, and socioeconomic challenges. The study examines ACEs in 25 states between 2015-2017. And now, with congressional authorization and funding, the CDC’s National Center for Injury Prevention and Control is implementing the PACE-D2A project. The CDC also made related resources on the Vital Signs report available.
Highlights from the other states—Connecticut and Georgia—will be reported here on ACEs Connection as interviews are completed (click here for a story on Michigan).
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