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Developing a Community-Wide Initiative to Address Childhood Adversity and Toxic Stress: A Case Study of The Philadelphia ACE Task Force

      Abstract

      The Philadelphia ACE Task Force is a community based collaborative of health care providers, researchers, community-based organizations, funders, and public sector representatives. The mission of the task force is to provide a venue to address childhood adversity and its consequences in the Philadelphia metropolitan region. In this article we describe the origins and metamorphosis of the Philadelphia ACE Task Force, which initially was narrowly focused on screening for adverse childhood experiences (ACEs) in health care settings but expanded its focus to better represent a true community-based approach to sharing experiences with addressing childhood adversity in multiple sectors of the city and region. The task force has been successful in developing a research agenda and conducting research on ACEs in the urban context, and has identified foci of local activity in the areas of professional training and workforce development, community education, and local practical interventions around adversity, trauma, and resiliency. In this article we also address the lessons learned over the first 5 years of the task force's existence and offers recommendations for future efforts to build a local community-based ACEs collaborative.
      The City of Philadelphia, the nation's fifth largest city, is home to some of the poorest neighborhoods in the country. The city has high rates of adversity, including child abuse, food insecurity, incarceration rates, substance abuse, community violence, and physical and mental health conditions. For example, Philadelphia has the highest rate of suspected and substantiated child abuse in the Commonwealth of Pennsylvania.
      Pennsylvania Department of Human Services
      Annual Child Abuse Report.
      More than 1 in 5 children in the city are food insecure, and 1 in 3 residents receive food assistance through the Supplemental Nutrition Assistance Program.

      Greater Philadelphia Coalition Against Hunger. State of Hunger: Pennsylvania 2013. Available at: http://www.hungercoalition.org/hungerreportpa. Accessed October 10, 2016.

      There are also many community-based organizations and service organizations that work to alleviate or mitigate the effects of these conditions on the lives of children and families. Too often, however, many of these organizations work in silos, on the basis of geography, services provided, or the specific issues they address.
      The concept of adverse childhood experiences, or ACEs, provides a framework for efforts to create linkages among these organizations. When issues such as child abuse and neglect, mental illness, parental incarceration, alcohol and drug abuse, violent crime, and others are seen as contributors to a common outcome, there exists the potential to break down barriers. It also provides the opportunity for health care organizations to collaborate with others in the community in which they serve to address the social determinants of health, as well as for academics to work more closely with community based organizations to provide data to substantiate practice. In this article we describe how Philadelphia used the ACE framework to create a collaborative, the Philadelphia ACE Task Force (PATF), which cuts across traditional disciplinary and institutional boundaries through collective focus on reducing adversity and its consequences.
      The PATF began in 2012 when the Institute for Safe Families (ISF), a local nonprofit organization, brought together several child health leaders in Philadelphia to conceptualize building a local initiative around childhood adversity and trauma. ISF's mission was to prevent family violence and child abuse, and to strengthen families to create nurturing, healthy environments that promote children's positive development. ISF had past success forging partnerships among diverse providers in Philadelphia to develop clinic- and community-based prevention programs in the areas of intimate partner violence prevention, positive parenting, and child development education. The initial aim of the PATF was to integrate screening for ACEs into pediatric primary care.
      ISF brought together physician leaders from the 2 freestanding children's hospitals in Philadelphia (The Children's Hospital of Philadelphia and St Christopher's Hospital for Children), a psychiatrist and traumatologist working at one of the schools of public health (Drexel University), as well as 2 local funders (The Scattergood Foundation and the Stoneleigh Foundation). All participants had knowledge of ACE research and wanted to develop initiatives that were informed by this research as well as by the evolving science of early brain development. At the first brainstorming meeting it became apparent that developing a task force—a citywide coalition of representatives from organizations that serve children and families, and who were interested in cross-disciplinary collaboration and communication around childhood trauma and adversity—was needed. The ISF was in a unique position to develop this collaboration for a number of reasons. First, it had a track record of working with child health care providers, the public health sector, and community-based behavioral health organizations. Second, because of the pediatric landscape of Philadelphia with its 2 large children's hospitals and many other academic medical centers, ISF was seen as a nonpartisan neutral organization. This allowed representatives of the medical organizations, which typically did not foster collaboration, to work together toward a common goal without issues of “ownership.” Third, because of its past accomplishments, as well as its ability to bring together representatives from multiple organizations, ISF was able to garner interest from local and national funding agencies.
      Over the course of several planning meetings, this leadership group (the 3 cochairs from the 2 children's hospitals and the school of public health—authors L.M.P., J.A.F., S.L.B.—as well as leadership from the ISF, Scattergood, and Stoneleigh Foundations) further identified 3 broad goals for the PATF: 1) identifying data needs and developing a research agenda to address those needs, 2) developing a cross-disciplinary, community-based approach to address child and family adversity, trauma, and stress, and 3) convening a national meeting on ACE and resilience.

      Developing a Research Agenda Around Data Needs

      Early in the development of the PATF, consensus was reached that research that addressed the specific contextual issues of adversity in an urban center such as Philadelphia was needed. The original ACE studies from Kaiser Permanente in San Diego were crucial in identifying the effects of psychosocial adversity in childhood and beyond. However, the specific questions that measured ACEs in previous studies, although universally important, might not reflect all of the salient stressors encountered by children and families living in poor urban communities, and that might have significant contributions to suboptimal outcomes. PATF leaders convened a research committee, comprised of local researchers in pediatrics, family medicine, nursing, and public health to identify projects that would expand the study of ACEs to better reflect experiences in an urban context.
      The PATF Research Committee determined that a first step would be to conduct community-based qualitative research to identify what some of these context-specific stressors might be. Two groups of researchers (1 from each of the 2 children's hospitals in Philadelphia) worked collaboratively to develop a focus group study to identify specific childhood adversities experienced by adults who grew up in Philadelphia. One group from the Children's Hospital of Philadelphia conducted focus groups with predominantly black adults living in west and southwest Philadelphia
      • Wade R.
      • Shea J.A.
      • Rubin D.
      • et al.
      Adverse childhood experiences of low-income urban youth.
      whereas the other (from St Christopher's Hospital for Children) conducted focus groups with Latino (mainly Puerto Rican) adults living in north Philadelphia.

      Pachter LM, Bahora Y, Witherspoon M, et al. Adverse childhood experiences (ACEs) in an urban Latino community: a qualitative study. Paper presented at: Pediatric Academic Societies Meeting; May 3, 2014; Vancouver, Canada.

      These qualitative studies identified an expanded list of childhood adversities and stressors that were common in urban settings such as Philadelphia, and also identified resilience and coping strategies that individuals used in the face of these stressors. Funding for these studies, as well as the study described in the next paragraph, was obtained by the ISF from the Robert Wood Johnson Foundation.
      Information from these studies, in addition to review of the literature and expert input, was then used to develop an “expanded” ACE survey, which included items pertaining to additional toxic stressors and adversities, such as witnessing violence, experiencing racism/discrimination, living in unsafe and unsupporting neighborhoods, experiencing bullying, and being in foster care (in addition to the traditional ACE items). The PATF contracted with The Public Health Management Corporation, a nonprofit public health institute, to administer this expanded ACE survey to a sample of 1784 adult Philadelphia residents who participated in the 2012 biennial Southeast Pennsylvania Household Health Survey. Some results from this study have been published and more analyses are being conducted and planned.

      Institute for Safe Families. Findings from the Philadelphia Urban ACE Survey. Available at: http://www.instituteforsafefamilies.org/sites/default/files/isfFiles/Philadelphia Urban ACE Report 2013.pdf. Accessed July 19, 2017.

      An article that described the prevalence of conventional and expanded ACEs and associations with demographic profiles showed that 73% of the study population had at least 1 traditional ACE and 63% reported having 1 of the new, additional ACEs.
      • Cronholm P.F.
      • Forke C.M.
      • Wade R.
      • et al.
      Adverse childhood experiences: expanding the concept of adversity.
      A second article from the PATF using these data described the association between cumulative ACE scores and health outcomes as well as the modifying effect of socioeconomic status.
      • Wade R.
      • Cronholm P.F.
      • Fein J.A.
      • et al.
      Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population.
      An additional analysis using these data to develop a factor analytic approach to ACEs measurement is under way.
      The PATF research agenda was on the basis of knowledge of the existing research on ACEs plus an evaluation of what was needed locally to provide a more comprehensive and context-specific approach to childhood adversity. It was the consensus of the PATF leadership that research coming from the task force should be pertinent to the goal of improving the identification of childhood adversities in Philadelphia while also contributing to the science by addressing issues of context and measurement. The agenda was strengthened by involvement of a cross-disciplinary group of researchers representing academic and practicing pediatrics, nursing, social science, epidemiology, public health, and family medicine. It is likely that this research could not have been done without the coordination efforts of the PATF, which obtained funding and allowed for collaboration among researchers at multiple medical institutions in Philadelphia as well as a nonprofit public health institute. The data from the PATF survey are available for other researchers to analyze, and such requests are evaluated by the PATF Research Committee.
      The Philadelphia ACE Survey study has subsequently been replicated in Shelby County, Tennessee. A telephone survey of more than 1500 adults has provided information on the prevalence of expanded ACEs and their effects on health outcomes for this community.

      ACE Awareness Foundation. 2014 Survey. Report: 52% of Shelby County Adults Experienced a Traumatic Event During Childhood. Available at: http://aceawareness.org/ace-survey/2014-survey. Accessed March 17, 2016.

      Organizing a Community-Based Approach to Addressing ACEs

      The Co-Chairs of the PATF and ISF leadership identified individuals and organizations who worked in the health care, behavioral health, social services, and public service sectors and who had experience or interest in developing trauma-informed approaches to psychosocial stress and adversity. The first meeting of the PATF took place in 2012 and was attended by 24 individuals representing the medical and public health communities, community-based organizations, behavioral health organizations, local charitable foundations, the state chapter of the American Academy of Pediatrics as well as local media.
      Before the first Task Force meeting, PATF leadership believed that an initial focus of the group should be the identification of optimal approaches to screening for ACEs in the pediatric primary care setting. Because the original ACE model coming from the work of Felitti, Anda, and others addressed the life course (ie, adult) consequences of childhood stress and adversity,
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      • Brown D.W.
      • Anda R.F.
      • Tiemeier H.
      • et al.
      Adverse childhood experiences and the risk of premature mortalilty.
      • Anda R.F.
      • Croft J.B.
      • Felitti V.J.
      • et al.
      Adverse childhood experiences and smoking during adolescence and adulthood.
      to use this model in pediatric primary care would require a great deal of nuanced discussion, including questions of who to screen (parents or children?), periodicity of screening, potential integration with other screening activities in primary care (eg, behavioral/developmental screening, maternal depression, etc), and logistics.
      • Garner A.S.
      • Shonkoff J.P.
      • Siegel B.S.
      • et al.
      Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health.
      • Van Niel C.
      • Pachter L.M.
      • Wade Jr., R.
      • et al.
      Adverse events in children: predictors of adult physical and mental conditions.
      Although at first glance this seems like a medicocentric activity, the rationale was that the nearly all children and families have some contact with primary pediatric care. Child health visits were seen as windows of opportunities to provide primary prevention and screening for toxic stressors and adversities (see also Steverman and Shern in this issue of Academic Pediatrics
      • Steverman S.
      • Shern D.
      Financing mechanisms for reducing adversity and enhancing resilience through implementation of primary prevention.
      ). Although there was much discussion of this at the first PATF meeting, no consensus was reached regarding focusing on primary care screening. Concerns were expressed about screening, particularly in a setting where services might not be available to address the issues identified. Others believed that screening, even without available services, could be helpful by opening up discussion of adversities and stressors, and itself was the beginning of intervention. The PATF continued to meet quarterly to grapple with this issue, providing information about national and local screening models, serving as a forum for open debate, and networking and bringing in new partners with additional interests along the way.
      Over the course of the PATF's 5-year history, the focus of activity shifted away from the issue of primary care screening toward a broader vision of creating a Philadelphia service system aligned through a framework of ACEs and resiliency. Part of this change in focus was the result of a wider, more inclusive representation of the community on the PATF. In line with the tenets of community-based participatory research, which emphasizes equitable collaboration to identify areas of investigation and developing action-based approaches to knowledge gain, the expansion of the PATF membership beyond health care organizations widened the lens of what was important to address from the perspective of the community. Although screening was a worthy topic of discussion, the addition of other voices on the task force brought to light the narrowness of that issue as a primary focus. Another driver of this change was the Task Force's planning of a national ACE meeting. This was initially planned to bring together a national group to identify promising primary care screening initiatives, but during the planning period it changed to a broader focus on how communities are creatively developing and mobilizing activity to address ACEs through collective approaches. This resulted in a 2-day National Summit on Adverse Childhood Experiences that took place in May, 2013.

      The Health Federation of Philadelphia. Summit Presentation PDFs and Speaker Biography Links. Available at: http://www.instituteforsafefamilies.org/summit-presentation-pdfs-and-speaker-biography-links. Accessed October 11, 2016.

      This meeting, cosponsored by ISF and the Robert Wood Johnson Foundation, was attended by more than 200 individuals and included sessions on ACE research, community-based approaches to ACE intervention, and policy and advocacy issues. The Summit participants and presenters were selected by PATF and ISF as leaders in trauma-informed training and implementation. Inspired by the National Summit, the PATF continued and expanded its focus on developing local community-based strategies to address ACEs and promote resiliency and recovery.
      Since the National Summit, the membership of the Task Force has significantly expanded, consistent with the expanded community-based focus. The PATF now includes representatives from the Philadelphia school system, federally qualified health centers, the child welfare system, juvenile court, affordable housing advocates, parks and recreation services, and legal advocacy groups, as well as representatives from neighboring communities in Camden, New Jersey and Delaware. Typically more than 40 individuals representing these sectors attend the quarterly meetings.
      In 2014, operations of the PATF shifted from ISF to the Health Federation of Philadelphia (HFP), an organization whose mission is to improve access to and quality of health and human services for underserved and vulnerable populations. This occurred because of the planned closure of the ISF and movement of staff and resources to HFP. After the HFP took over the coordination of the PATF, it embarked on an internal visioning process to identify priority areas of focus for the future. Three major areas of focus were identified by members of the task force: 1) educate the community about ACEs and their effect, 2) develop a better understanding of interventions available in Philadelphia to address childhood adversity and trauma, and 3) incorporate ACEs research and work into curricula of undergraduate and graduate medical, nursing, allied health, and human services programs. Initial meetings were informal ways of learning what each member and their organization did, and disseminated information on ACE-informed practices and training programs within the Philadelphia region. Over time, self-education and networking led to the desire to add more goals to the collective effort. Working groups were established in each of the 3 focus areas and funding has been garnered to support 2 of these work groups. The Community Education workgroup received funds from the Atlantic Health System and First Hospital Foundation to create messages about ACEs and resilience that resonate with Philadelphia residents. The Professional Development Workgroup, with support of a Casey Foundation Fellow, has developed and piloted an introductory curriculum on ACEs for the College of Health Professions at Temple University, is meeting with the National Board of Medical Examiners to explore having questions about ACEs included in medical licensing examinations, and is developing a tool kit for faculty and other higher education educators to assist them in creating new courses, or refining existing courses, to reflect and embed knowledge about ACEs, toxic stress, trauma, and resilience.
      Communication, within the PATF participants as well as toward the greater ACE community, has been significantly enhanced by the ACEs Connection Network Web site.

      ACEs Connection Network. Available at: http://www.acesconnection.com. Accessed October 10, 2016.

      The ACEs Connection Network provides a venue for sharing conceptual models, barriers and successes, and real world examples of ACE efforts around the country. PATF established a Philadelphia-specific group, Philadelphia ACEs Connection,

      Philadelphia ACEs Connection. Available at: http://www.acesconnection.com/g/philadelphia-aces-connection. Accessed October 11, 2016.

      to facilitate dialogue and information-sharing among local interested parties. This has become a very efficient way to keep our task force members up to date with recent activity between meetings and simultaneously serve as a public compendium of task force work. There are currently 249 members of this ever-expanding group (http://www.acesconnection.com/g/philadelphia-aces-connection).

      Implications and Lessons Learned

      The first 3 years of the PATF were defined by changes in focus and scope (Figure). Initial activities focused on developing a local base of members, conducting a study to better understand the local prevalence and effect of ACEs, as well as the planning for the National Summit on Adverse Childhood Experiences. That planning process, as well as a great deal of “word-of-mouth” interest in the PATF helped us shift our focus from emphasizing what today remains a controversial issue—screening for ACEs in primary care—to coordinating and convening a larger, more community-based consortium of individuals and agencies committed to addressing childhood adversity and psychosocial stress in multiple sectors and across multiple strategy levels. Inherent in this expansion of focus was the need to branch out and develop smaller working groups that are more able to address specific issues and initiatives on an ongoing basis. Many lessons were learned, and some of their implications are identified in the following sections.
      Figure thumbnail gr1
      FigureTimeline and evolution of the Philadelphia ACE Task Force 2012 to 2017.

       Local Research Matters!

      The PATF Research Committee complements the work of the Task Force. The committee's agenda was initially focused on gathering qualitative local data, the results of which informed the creation of a larger quantitative study which has broadened our conceptualization and measurement of ACEs. This research added an extra dimension to the seminal work of Felitti, Anda, and others
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      • Brown D.W.
      • Anda R.F.
      • Tiemeier H.
      • et al.
      Adverse childhood experiences and the risk of premature mortalilty.
      • Anda R.F.
      • Croft J.B.
      • Felitti V.J.
      • et al.
      Adverse childhood experiences and smoking during adolescence and adulthood.
      by including community-level adversities in the measurement of ACEs. Qualitative and quantitative data on the occurrence of ACEs in Philadelphia provided task force members with a solid local linkage, and brought the issue into greater focus with increased local pertinence. Members can now go back to their institutions (and their Boards and funders) and provide strong justification for addressing childhood adversity and stress, as well as advocate for trauma-informed approaches to care. Although many of our researchers initially saw the research agenda as addressing “big picture” issues in theory and measurement, we have found that this work is as much applied action research as it is theoretical, and we have been reminded of the power of a good argument with good data backing it up to change things on the ground. We recommend the development of multidisciplinary and multi-institutional research collaborations that could be well situated to address the next phase of research in child adversity and trauma from a holistic perspective.

       Trauma-Informed Professional Training is Essential

      The fact that the PATF identified professional education as 1 of the 3 areas of critical need speaks to the importance of training and workforce development (see also Magen et al,
      • Magen E.
      • DeLisser H.M.
      Best practices in relational skills training for medical trainees and providers: an essential element of addressing ACEs and promoting resilience.
      Brown et al,
      • Brown J.D.
      • King M.A.
      • Wissow L.
      The central role of relationships to trauma-informed integrated care for children and youth.
      and Girouard et al,
      • Girouard S.
      • Bailey N.
      ACEs' implications for nurses, nursing education and nursing practice.
      in this issue of Academic Pediatrics). Although developing and implementing trauma-informed curricula for health professionals was an important first step, more needs to be done to assure that all service sectors develop an approach to incorporating these issues into their professional training. Curricula need to be developed for the medical, social service, community health, and the child- and family-serving sectors. These curricula need to include content specific to life course effects of childhood adversity, trauma healing, and promoting resilience. This is an area that the PATF workgroup on education and training is presently identifying ways to address. Developing universal core content for such a curriculum, which can then be supplemented with discipline-specific information, might help balance the needs for standardization of training and providing specialty-specific content. For this to happen, local and national advocates need to push for professional and educational organizations to include such training as a core component of professional education at all levels, and a recent meeting of PATF members and the National Board of Medical Examiners to discuss incorporation of ACEs and trauma-specific material in professional examination is an example.

       Sustainability Requires Financial and Personnel Support

      Although all members are committed to the activities of the PATF, most are volunteers and cannot commit large amounts of time. It is imperative that external support and infrastructure be available for such initiatives to succeed. The PATF is fortunate to have strong community-based organizations such as the ISF and the HFP, who provide needed staff support and organizational leadership. Local funding organizations, such as The Thomas Scattergood Behavioral Health Foundation and The Stoneleigh Foundation provided much needed financial and staff support for the administrative and organizational aspects of the PATF.

       Establish a “Neutral Hub” for Collaboration

      The fact that ISF, and now the HFP, are not affiliated with any single medical or health care institution allows for collaboration without turf wars, and also provides easier access to service sectors that might be hesitant to be involved in an initiative directed by more medicocentric organizations. This might lead to greater sustainability in the long run. Broad-based community collaboration places the organizing agencies in a better position to obtain external funding. Communities need to identify the local agencies and individuals who are best positioned to come together and initiate similar collaboratives as the one developed in Philadelphia, but on the basis of unique local strengths, needs, and infrastructure.

      Conclusions

      The power of applying the science of ACEs to our work is that it compels us to make connections. Connections among negative experiences and adversities, connections between these experiences and our health and well-being, connections among service sectors and systems, and connections among people. When we embrace the ACEs framework we can no longer be comfortable with focusing on solving single issues or applying single strategies.
      The evolution of the PATF exemplifies how using an ACEs framework can help broaden a vision and foster stronger existing connections and create productive new relationships. Begun as an “invitation only” Task Force primarily made of up of pediatricians with a single focus on integrating ACE screening into pediatric primary care, the group has transformed into a multisector collaborative working at several levels to forge cross-system solutions to ACEs in a community-based collaborative framework. The existence of the Task Force quickly spread by word of mouth and professionals throughout Philadelphia and the Delaware Valley were enthusiastic to participate. No one was turned away, resulting in a much broader and diverse membership than had been the original intent. This was accomplished through a combination of carefully planned and spontaneous organic changes. The National Summit, hosted in Philadelphia, shined a spotlight on communities that were doing important work on ACEs throughout the country. This in turn influenced the PATF, and finally, as the Task Force matured and expanded, there was opportunity to reflect on the Task Force's work, recognizing that much of what was accomplished had been through the development of strong connections, which could now be put to work to accomplish a much broader vision. Going forward, the Task Force will continue to reflect on how it is capitalizing on the ACE framework to broaden its work even more to build a healthy and resilient community for all Philadelphians.

      Acknowledgments

      The authors thank Martha Davis and Sandy Dempsey, executive directors of the ISF, Task Force staff Carolyn Smith-Brown, Caitlin O'Brien, and Alyson Ferguson, as well as the Thomas Scattergood Foundation, The Stoneleigh Foundation, and the Robert Wood Johnson Foundation, all who have supported the PATF.
      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and AcademyHealth, with support from the Robert Wood Johnson Foundation (# 72512 ).

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