Share Public Health podcast transcript, Mental Health: The Need for Trauma-Informed Training

Transcript: Season 1 Episode 2

Laurie Walkner Welcome to share public health the Midwestern Public Health Training Center’s podcast connecting you to public health topics, issues, and colleagues throughout our region and the country, highlighting that we all share in public health. Thank you for tuning in to the series focusing on mental health. In this series we will explore mental health through the lenses of schools public safety and the business community. Be sure to check the notes to get links to resources mentioned in the podcast.
Maya Chilese Well thanks everyone for joining us today this is Maya and I’m here today on behalf of the Midwestern Public Health Training Center. This is a podcast series on mental health. Joining me today are three guests and we’re talking a little bit today about ACEs in schools. So I’d like to introduce our guests, but I’ll ask them to say a bit more about themselves. Welcome and thanks for joining with us dr. BeLue, Kemba, and dr. Barnes. Would you guys say a little, please, about yourselves?

Rhonda BeLue I am Rhonda BeLue. I am professor at SLU University and the chair of health management and policy. I have been doing community partner and health services work in a variety of community settings and schools in the US and globally for the past 20 years or so. I’m glad to be able to speak about this topic, so that we can continue to address diverse childhood experiences and trauma. Which at some point when we explain the difference and how they’re related, so that we can move the field forward and help the next generation of youth be successful.

Kemba Noel-London My name is I’m Kemba Noel-London. I am athletic trainer by trade and I’m a doctoral candidate at the University. Dr. BeLue is my just ever so important and faceted mentor and I work in a school-based health center. My work as athletic trainer led me to public health and health management policy, and through that I got introduced to ACEs both in the work that I do at the school-based health center but also in the research that I do with Dr. BeLue.

Alicia Barnes I’m dr. Alicia Barnes. I’m an assistant professor in the department of psychiatry at the School of Medicine at St Louis University. As part of my role I work in the community providing child and adolescent psychiatry to children that are frequently faced with adverse childhood events or toxic stress. Being predominantly in urban St Louis community centers. I’m working in fairly qualified health organizations. This is a special area of interest to take a step back and say: what are the public health interactions or what are the interactions in schools that are intersecting with the actual diagnosis that I could see on a day to day basis in the clinical setting?

Maya Chilese Great. Thank you so much for joining with us all of you and Dr. Barnes. I appreciated your comment there at the end around helping us to think about the role of Public Health in addressing mental health. I think that’s really the land that we’re living in here today in thinking about this topic. Children’s mental health of course touches a variety of systems as it relates of course to the national initiatives around children’s mental health system. In the system of care recognizing that there are indeed a variety of partners who can contribute to wellness. Our conversation and our likely listeners are public health professionals who often are asking: what is our role and how do we as public health strategists contribute positively to this conversation in our community? So thank you for joining us today I would like to just kick it off by asking you three to talk a little bit more about, what ACEs are, how they affect children, and provide a little bit of a background around what that means for our listeners?

Rhonda BeLue I’ll start a little bit and I’ll actually let Dr. Barnes expand with clinical knowledge. I wanted to start by saying that we’re going to talk about ACEs or adverse childhood experiences, but there are other terms that are broader and other terminology, including like Dr. Barnes said toxic stress, or even just trauma. I would say that ACEs are a specific measurement of that exposure to trauma, but certainly not all inclusive of everything that could really traumatize a child and have effects into their adulthood, including further mental health effects and physical health effects, effects on their social mobility and a multitude of factors can occur immediately after experiencing trauma or adverse events in childhood. So we might hear a lot of terminology turn around including trauma, toxic stress, and adverse childhood experiences.

Thereby I will speak a little bit about some pretty common measures or categories of adverse childhood experiences. But I do want to make note that trauma can be something that traumatizes one child may not traumatize another child. It’s really an individual experience and just because you’re teaching a child in a school-based setting that doesn’t have a high ACE score which you can measure, that doesn’t mean that that child was not traumatized.

So this is a growing field and something that we really need you to consider from a public health perspective as Dr. Barnes said from a social health and well-being perspective, an economic perspective, and an educational perspective. Because adverse childhood experiences in early childhood trauma affect an individual’s well-being from a multi-dimensional perspective across a life course. Dealing with ACEs in a school-based setting is also important in that teachers, peers, staff, and coaches realize that this is not a poorly behaved child. This is a traumatized child. This is a hungry child. Food insecurity is typically not one of the ACEs, but it’s certainly traumatizing. Well poverty is an ACE, food security is associated with poverty, but to realize and how to create disciplinary or not as disciplined. How to redirect the children? How to educate children as opposed to treating them as being poorly behaved, but understanding they’ve been traumatized. How to create trauma-informed school systems? At this point we have trauma-informed healthcare, but how do you really create a trauma-informed school system and what are the resources in the training that’s necessary to do that?

Kemba Noel-London And then when you think about going to schools and if you have school-based health centers that function in those as well. It’s going to be important in the community that there is trauma-informed care for the providers, but then again, like Dr. BeLue mentioned, for the teachers as well. Because you don’t want a teacher or provider to now re-traumatize that child when they’re coming to school for this avenue to learn, or they’re seeking health care from a school. So the last thing that you want them is to feel ashamed, victimized or re-traumatized. They’re seeking health care then when you get to my avenue of sports and allied health professionals this is not something that we commonly talk about in the allied health professional world. Then when I see coaches that don’t really understand or really separate the fact that this child might be experiencing all these things at home. This might be why they’re responding the way that they are, or why they’re not coming to practice. There’s a disconnect between what might be happening to a child, influencing behavior from the coach and foremost.

Rhonda BeLue I will ask, even though I know you have a new and rapidly developing area of expertise, if you could say a little bit. I’m sorry if I’m pre-empting a question here, but if you can say a little bit about what a school-based health center is? What schools typically have a school-based health center? Because I think it relates to trauma and poverty in many ways. The legal premise behind school-based health centers is to circumvent the typical barriers of access to care and underserved and safety-net populations. So the most school-based health centers are located on the school component. That immediately removes it back to the barrier of transportation. The theory is if we put these school-based and healthcare right where these kids spend 90% of their day, then that now reduces the likelihood that they’re going to be home sick. Because they can’t go to a doctor, right? Because they can come to school and go to the doctor at the same time.

Kemba Noel-London Yeah. Then with school-based health centers as well they are also moving towards a trauma-informed approach. So with school-based health centers the most common model involves having a nurse practitioner. It’s like some primary care as well as a mental health or behavioral health specialists too. In the model and school-based health center that I worked at, the school-based health center worked very much in tandem with the social worker of the school and disciplinary order or action of the school. In order to, one, use behavioral health as an alternative to suspensions. Instead of just immediately suspending a kid for, say they drop the f-bomb on a teacher or something, we take them to behavioral health and are able to figure out what is the underlying reason as to why this behavior happened and not so much just treat the symptom initially but recognize given the population they were in there might be some underlying things happening as to why this kid had an outburst at the teacher or some authority figure. Really social work at a school what we saw happening is that these suspensions dropped. We reduced, in terms of in-school suspensions, and all those things, when we just changed the way that we dealt with discipline. Instead of just having the zero-tolerance policy for everything there was more understanding discipline with dignity, or are we discipline with a certain understanding going in behind.

It’s a little bit harder for me when I have my coaches who always rub some dirt in it. That’s always the answer to everything regardless if it’s the actual physical injury. This is a mental injury because that’s something they’re not used to really dealing with, or they themselves would have come up in similar neighborhoods. They have the mindset of well it’s just something you have no choice but just overcome it or let it just keep you where you are. Without recognizing there are other things that are going into why this child can’t just make the choice to get over it. I think when we expand, or I’ve been trying to expand in terms of concept of trauma-informed coaching. I’ve spoken with coaches who feel bewildered in terms of: how do they now coach a team where one of their players just got shot? How do you now come to practice and just perceive it practice like nothing happened? When these kids are now surrounded by gun violence and they’re being impacted by gun violence in a very real and personal way. How do you go on with practice? How do you now navigate that field? A lot of coaches now, which is interesting and great in the world of sports, are recognizing we can’t do it the way that we were doing it before because this is a whole different ballgame. I think those kid’s coaches also work in the schools that is now trickling into the schools as well because they’re teachers and they see them every day. You find coaches now become advocates for trauma-informed care within these schools and within covering a care team set up for their athletes and those things. They become very invested with the holistic program and discipline for their students and their athletes. Not just this one single dimensional pathway.

Maya Chilese Kemba that’s so interesting and I really appreciate you extending the lens around thinking about how a trauma-informed approach doesn’t just have to live in a clinical setting. I think I’ve heard you guys talking a little bit about what it means to have traumatic experiences and how although the mental health community, if you will, or the mental health system of care is really making great strides. Thinking about what it means to provide a trauma-informed care there are other venues in which that expands. I really appreciate you bringing that up. I just wanted to highlight, I think I heard such great conversation. I heard several valuable things that I wanted to just pull out and just sort of pause for a moment while we’re talking a little bit more about what schools are doing. Then, perhaps, get back a little bit to that. The one thing that I think is important to note about this conversation is that I think we’re seeing a valuable shift in redefining the way we think about trauma or crisis.

Dr. BeLue, I think I heard you talking about this as at the beginning, where trauma is an individualized experience and how someone defines a crisis is very personal to every person. It’s important to note that and I think that when we’ve talked about mental health in the past it feels a little bit like there used to be this box and that was really only considered related to significant or chronic psychiatric disorders.

Today’s world we’re recognizing that things like ACEs, the adverse childhood experiences, or events contribute to people’s life experiences differently or the experience of toxic stress. I was thinking about this the other day when the WHO, the World Health Organization, came out identifying work burnout basically as a health condition. I think one of the things that is valuable for us to recognize, and this is what I’m hearing from you, is this is a bigger conversation. It’s important for us to recognize that this happens in a variety of ways outside of the things we would have normally considered as a traumatic event. Clearly things that are traumatic like a school shooting or things like that you would easily define as traumatic happen. People have experiences based upon those, but there are other things that can contribute to that trauma or toxic stress.

I heard you also note things that are related to the social determinants of health, which we know public health professionals think about. I heard you talk about how the experiences of historical trauma or how cultural and elements or racism, the long-term experiences of racism, can affect marginalized populations in that way. One of the things I wanted to make sure that we covered, Dr. BeLue I heard you also say at the beginning, talking about sort of measures or categories around that. I think it would be valuable to talk about that a little bit more.

Then I would love to hear you guys say a little bit more about what schools are doing. Also, we’re recognizing that while you’re talking about some innovative experiences that some schools are having that we still have a lot of schools and particularly in rural communities that don’t have those same resources. Thinking about what we’re seeing that is working really well, but what might you say to school systems that perhaps don’t have those same resources? What might we advise public health partners or schools to be thinking about in terms of addressing those issues?

Rhonda BeLue From my understanding of the current literature, I’m not aware that rural stressors or the context of a stress in rural areas, that stress children may go through that’s contextually related or specific to being in a rural area is even accounted for in the ACEs. Certainly things like child abuse and domestic violence and exposure to violence could happen anywhere and those things are pretty universal, but I am not so much aware of really any. I’m sure there’s literature out there but a critical mass of literature that really addresses some of the rural phenomena that a child may have to go through that may be different than the typical ACEs with those in an urban setting.

I have a friend and colleague from Pennsylvania and her name is Lisa Davis and she is the director of the office of rural health there. She used to always come and speak in my class and she would just talk about those nuances and differences in routine training that are required in health care. Even some of the most basic things. If you’re an EMT in an urban area you have standard EMT training. If you’re an EMT in a rural area you have to know how to take a tractor off of someone. You don’t have to know how to take a tractor off, I mean I know that not all rural areas are not characterized by having tractors, but you usually don’t have tractors in urban areas. That’s something that you have to know how to do. You have to know how to deal with farm accidents or occupational injuries that relate to more rural economy and the context that individuals live in.

So I would definitely advocate for some more contextually specific issues that a child or adolescent would face in a rural setting and including rural poverty or failed farming or farming bills or other things that might happen in a rural setting that are not necessarily accounted for or a parent who’s disabled from a farming accident a number of things can happen or boredom or lack of access to other resources that can cause personal trauma or stress. I think that we definitely need to advocate for some more research. I think that’s definitely a necessity.

Kemba Noel-London That just makes me think of like my own clinical experience of going to actually getting trained in that too. In last clinical area site that was out in the county. Then my first job was in Swansea South Carolina. I had a student come in with injuries from squirrel hunting, and then somebody like was in the back of a pickup truck and transporting some farm equipment and had serious injury and then they came to see me because I was the easiest person for them to get to because I am always at the school after hours with all kinds of practice. I was a health care provider. I was not into training that I received so then now I had to essentially learn on the fly all the different contexts and injuries that were not necessarily athletic related but I still needed to treat because this was the population I was in. As you’re saying I’m just like nodding and thinking yeah this is a very real thing that’s not something we get taught.

Maya Chilese I appreciate the dialogue around that and I guess part of the think I think is important to note you guys have been talking about trauma and toxic stress and the ACEs is that the increase the need for public health to participate in the awareness of what those things mean. For my perspective having worked both as a clinician end and in public health broadening or perhaps expanding people’s sense of awareness of what those things mean that it isn’t just I’ve lived in a war-torn nation or that you survived a school shooting or some of those genuinely horrible events and that if you didn’t have those then you must be fine. Just recognizing that there are many other things that somebody could experience as traumatic or as a crisis that can contribute and that there might be other things that are cultural with which you were just talking about perhaps from rural communities that could be interpreted that way or could negatively impact children to a degree that is causing them trauma. I appreciate the recognition of that.

What I might ask is if you could say perhaps even a little bit about the prevalence. What does data show in terms of the prevalence of ACEs or trauma or toxic stress in the in the children’s system?

Rhonda BeLue Sure. I will actually give you some information from a national data set that I’ve been working with since 2003. There’s a data set called the National Survey of children’s health, it’s a CDC National Center for Health Statistics product. It started out in 2003 I believe there were about a hundred and two thousand children represented. Given the economic times now in 2017 there’s about 50,000 kids. In 2011 they started measuring ACEs and the most recent estimates and again these are just prevalences although they started collecting the data every four years in 2003, 07, 11/12 and then sixteen and now it’s become an annual data set starting in 2017. It’s multiple cross-sections so it’s not the same child followed over time, but they would say that 64% of actually adults, this is from another measure, have reported ACEs and more than one in five people over a lifetime have reported three or more ACEs, in about 12% of people four or more ACEs so it’s pretty prevalent.

Some of the work that I’ve been doing really has to do with not just adding up ACEs, right, I mean things are qualitatively and contextually and quantitatively different. You know, perhaps having lost a parent or experiencing sexual abuse don’t qualitatively have the same effect so as opposed to just adding up I’ve had four ACEs or I’ve had five ACEs to really identify what the cumulative effect is based on on the particular ACE but you do have a good majority of the population that’s had least one and I will say back to some other points that you mentioned before is that every…that trauma is individualized.

We’ve talked about that a few minutes ago but that also just because somebody doesn’t appear to be traumatized doesn’t mean they’re not traumatized. You could have the high-performing or a quiet student that seems to be well adjusted that is traumatized and actually does need some therapy or some care or some intervention. I will just put it out there and ask Dr. Barnes for her opinion because she’s the clinician that trauma-informed education and trauma-informed school-based programs and trauma-informed coaching are not just for those that have stereotypical signs of having experience of an ACE or trauma. They could be for everyone even for the child that doesn’t even recognize that their experience is trauma and can’t articulate it. And don’t necessarily have those signs that get them sent to in-school suspension or that put them on the the administration’s radar. All students just given stress that kids go through from cyber bullying to whatever they’re going through. I think a trauma-informed approach where people come from an understanding that their behavior is their current coping mechanism and they need to be taught healthier ways.

Kemba Noel-London After these statistics that Dr. BeLue mentioned from the NSCH, the National Survey of Children’s Health, you look at that just under 45% of those children have experienced at least one ACE. So that’s just a national dataset and then 56% of those children have experienced one or more ACE. That’s pretty consistent from 2011 to 2016. That hasn’t really fluctuated, so it’s a fairly consistent experience when we’re looking at the national sample of the children in the United States.

What being said it’s not an equally shared experience when we see that when we look at the different racial and ethnic groups non-Hispanic black children they’re 61% of them are more likely to experience one or more ACE than when you look at non-hispanic white children. It’s just important to note that when we look at national data sets that the experience of ACEs is consistent across the board, but it’s just when we go down to racial ethnic differences it just seems that the black and non-hispanic black and brown kids are just experiencing ACEs at an increased level. It’s a little bit concerning.

Alicia Barnes And I would say with my review of the literature I agree with some ACEs are more qualitatively significant. One study I’ve read was that maternal mental health or paternal mental health is significant. If you think about systems of care and a caregiver affecting the entire family and one of the things that we’re facing is as parents are facing mental health issues, as they’re facing substance abuse issues, or opiate abuse these are things that trickle down generationally. Schools are one of the places that I see that this interface first happens between the family and a system of care where there can be an intervention. So that’s one of the I think even if it’s to go back to your other question and what do we do in schools that may not have as many resources is even if there’s an awareness and the teacher population or whoever the staff is of trauma-informed care that can make an enormous change.

One thing in this work I’ve seen is asking about children not what’s wrong with them but what has happened to them. If that model is translated to any school system I think it changes the dynamic and it changes the ability to open that dialogue for children, whether in a rural or an urban setting. But that caring for families and figuring out ACE is one or more qualitatively significant. I think anecdotally as well in my practice I find that a lot of times when maternal mental health is maternal depression, postpartum depression, postpartum psychosis, when these issues arise it makes treating mental health just significantly more challenging. Then if you’re adding more children in that family it has a different effect overall because now you’re talking about three children maybe instead of just the one child sitting in front of you because his isn’t just the child sitting in front of you it’s the family and then the community also affected by that family.

Rhonda BeLue There’s some work one of the authors is Dariotis. It’s a team that was brought together by Mark Greenberg who’s a specialist in school-based prevention. They’ve had success in using mindfulness and yoga to to help kids reduce stress and toxic stress and to improve behavioral and academic outcomes, but of course again that’s contextual as well. If you’re in an urban school or a rural school I don’t think it’s necessarily the act of just doing mindfulness meditation it’s whatever is de-stressing from a contextual point of view, whether they have music class or however they want to allow students to reduce their stress or to break anger elimination or just to calm down.

Some of those programs can be done for free even as simple as we’re gonna have a music hour. I think as we all know and Kemba can speak to this that compared to decades ago when I was in a school we had the Presidential Fitness Test. We exercised a lot. We were always, I was always outside when I was a child and there’s biological research evidence that exercise and movement reduces your stress. I think in a school-based setting because of testing and other things we’re doing the kids a disservice because we’re reducing…PE you don’t have to move. Sometimes you have PE classes where it doesn’t involve any movement because of risk or inappropriate staffing but even things like making sure that children are getting some exercise or music education the things that we’re cutting out of schools are actually the things that could help counteract trauma and give some kids some better coping skills. In terms of policy and advocacy you can advocate for those things that they’re actually taking out of the schools. It would would be helpful in the school system and the families or the parents are the ones that have to decide what contextually is that for the school system.

Kemba Noel-London And then when you think about you’re going to go with these things that are being taken out as if your school district doesn’t have any money to provide like extracurricular activities after school right and then they don’t have physical activity and now that child’s not going to move at all because now they don’t have any interscholastic sports and stuff after school tonight supplement for that lack of movement with physical education. There’s a lot of barriers that a lot of athlete directors and there’s one study that discuss like different barriers athlete directors face in terms of one having athlete trainers in terms of making sports safe for the kids to participate in. But one of the main things that they came up with is that they don’t have any power, like budgetary power at all. They get told this is how much money you have for your sport programs and athletic directors have to figure out how to make that work and a lot of the times coaches don’t get paid enough, so then you don’t get good coaches and then you don’t have a sport program. You know there are a lot of things that are going into policy-wise why schools don’t have access to sports and like BeLue mentioned, sports are one avenue that you can utilize to de-stress or kids utilize to de-stress.

It also helps them build a sense of community outside of school. I know in the school that I work in when it comes to football season from the summer all the way up to November we see them probably more than their parents do. We see them during the day during the summer after school. It becomes very much of this family thing and it’s another way for them to be away from gun violence or be away from that home where they’re experiencing all this different kinds of trauma too. So on a policy level there isn’t any advocacy to support schools and to support school systems to have even these simple things as sports and proper physical education as a simple way to do trauma-informed care and de-stress students. We’re really doing them a disservice that way as well.

Maya Chilese Kemba, thank you for that. You sort of tied back around to some an important notes that I heard the three of you discussing at the beginning of this podcast was the relationship between social, emotional, and mental well-being, and physical health. I think I would like to stress that for our public health professionals that may be listening is that when you’re thinking about, well how can I help, I don’t know anything about mental health that we recognize the relationship there and I believe Dr. BeLue you were talking even a little bit about the likelihood of people who might experience trauma or toxic stress or have experienced one or more ACEs are more likely to have X, Y, and Z risks or negative health experiences, physical health experiences so I think that’s important to note. In the mental health community we might refer to those things as sort of co-occurring that there’s more than one thing happening at a time and that they relate. We also know that literature shows that adults who have experienced mental health challenges over their lifetime are significantly more likely to also have physical health complications, be those chronic or acute, and less likely perhaps to even seek care for those so I really appreciate the conversation today about how those things pair, and I also heard you talk in this last little segment about several things that I sort of was seeing in my head about the ten essential public health services wheel.

I’d like to help us move this conversation to thinking about well how could Public Health be a part of the solution? What are things that public health professionals, public health departments can do to be involved? What are some of the things that you say I heard you talk a little bit already around advocacy and policy perhaps even having a role in helping to collect local data around these issues, but what would you say to our public health listeners about how they could be involved and what takeaways you might have for them?

Rhonda BeLue Something I do for my students who are in MPH students and public health professionals in training is that I provide them with training on trauma-informed care and trauma-informed interviewing so that when they go out into the community whether it’s a school system or other community-based organizations that when they are talking to clients or community members that they are speaking from a trauma-informed perspective and I think we did two four-hour trainings that were very useful. I think that it should really be a part of public health education in general so that students and professionals that work in frontline public health, I did I spent some time in in actually Nashville’s City County Metro Public Health Department and for those frontline public health workers that interact with clients to really understand how to interact from a trauma-informed perspective I think is helpful and it should just really be part of public health education in general. I think that that can be one way to educate the public health workforce in trauma-informed interviewing and trauma-informed interactions and just the basics of trauma-informed care, whether you work at the reception desk of a public health organization or you are in health behavior or an infection control. You should have an understanding of trauma-informed approaches.

Alicia Barnes And I would say, so I actually wear two hats so I’m a child psychiatrist but I also have my master’s in public health. I think one of the reasons I sought that out was because there’s that need for a bridge. Any child psychiatrist will tell you there’s a shortage nationwide; there’s no county in the United States that has enough child psychiatrists. The projected need is 30,000 and we have 8,000 total nationwide, so I think that partnership in that bridge working with public health professionals is essential because we have to take a wider scope and a wider lens and partnering with schools and saying okay what other interventions can we implement, kind of trying to head off some of these more severe illnesses. If there’s a trauma, resilience is built by having somebody intervene in the course of the trauma occurring. In the definition of toxic stress it’s just the stress that’s continuous and bombarding without any relief of that stress, nobody to give you a hug if we fall down, nobody to talk to when you lose a friend. Having public health professionals trained in trauma-informed care, having teachers trained in trauma-informed care, connecting with clinics for more severe cases, I think that’s the model that we’re leaning towards for the future given the absence of 20,000 child psychiatrists.

A part of my role as training residents and it doesn’t look like those 20,000 are coming very soon so I think that it’s essential to engage with public health professionals school-based programs. It’s really kinda of to take a broader scope of what the needs are.

Kemba Noel-London I was going to agree with Dr. Barnes, like I said I’m an athletic trainer in the allied health world so now we’re just really broadening that lens even wider right. I think she’s right in terms of we need to engage with public health professionals. Also, clinicians as well we need to really actually be trauma-informed and not just the typical, I’m making air quotes right now, the typical clinicians but just also clinicians like myself and athletic trainers and physical therapists and occupational therapists. Because you think there are occupational therapists who work in jails and prepare people to come back out and to acclimatize to society and those things as well they also need to be trained in trauma-informed care, especially now that we’re thinking about school-to-prison pipeline. If you have people working in schools like those things that they also need to be trauma-informed as well so I think broadening the scope and your community resources is really important so that when you as a public health professional are trained your advocacy shouldn’t just only be towards policy changes, but also engaging with the people around you who make up their clinician pool. So that you now spread the word to them so that okay yeah we work in this community, these are the things that we currently see, I think it’s really good for you to become trauma-informed so that when you go in to do work into that community they’re actually facilitating the movements and not also in unintentionally hindering progress.

Rhonda BeLue I’ll come speak from the two hats, or maybe it’s one hat. Turn it to the front, turn to the back, so I’ll speak from two hats. First, from having worked in local public health to make sure that we’re beyond some of these national data sets, that we include understanding of trauma and ACEs in our surveillance and our needs assessments even as health departments are starting to collaborate more with hospitals, in terms of community health needs assessments and to really look at factors related to trauma and ACEs in needs assessments and in surveillance from a local level not just from this national level. And leading that and into this partnership with hospitals, I’m going to put on that health management and health services scholar hat and that hospitals, albeit for-profit, when you go into a Children’s Hospital it looks like Disneyland, and that is to reduce trauma and to improve patient experiences so that children who are ill can heal and have a good experience and have a better emotional experience, which is going to help their physical healing. Whereas our schools don’t look like that.

I mean from of management and from an org theory perspective, having a healthy organization and having all the way from appearance to function also affects someone’s ability to build resilience and to administer trauma-informed care. If you look at a lot of our schools, a lot of our rural schools and our urban schools, they don’t look like Disneyland or Disneyworld, whichever coast you’re on, really having that trauma-informed design. It doesn’t feel very good to go to school and have hospitals look better than schools. It looks like a prison or it doesn’t look nice.

Also, you have underpaid teachers and the whole environment is stressful and from an organizational development and or capacity perspective. You have schools and staff in them that have workplace stress and trauma like you mentioned from the World Health Organization. If you have a stressed out organization and stressed out teachers and burnt out teachers it’s going to be hard for them, they’re going to need their own trauma-informed care and it’s going to be hard for them to deliver that type of education to the children. It really starts from that organizational development, organizational management and policy perspective that you build schools as healthy organizations if you’re going to deliver a trauma-informed positive caring environment. I mean there’s a positive affect or producing positive affect might seem trivial but it is the difference between going into a school that’s crumbling with gray walls and flourescent lights and versus going into a school that has nice facilities and flowers does have effects on your mental health and having stressed-out teachers and high teacher turnover and inadequate resources exacerbates a trauma and makes it hard to fix it. I think that if a public health perspective really recognize that trauma and includes that in community health needs assessments when you’re partnering with health care organizations but from just an organizational capacity and organizational development looking at students and looking at schools as a system of care and education to really think about how do you build a healthy school system all the way from the organizational climate and the morale to the appearance of that school and think about what it does to the children. Then who you have high teacher turnover, stressed-out teachers, and a school that’s visually unappealing and then you wonder you’re why are the kids acting out and not performing well and it’s really not a question we should ask.

Kemba Noel-London I mean this is one…I will say the students know, the kids know, when an administration or a district or people in charge of teachers care. They know. They are able to decipher very, very quickly if this person genuinely cares about them or if this district cares about them, or if they don’t. A lot of these times with the students that I’ve worked with their effort is very much mirrored by the effort that they’re given. If they perceive very much that people don’t care, if they do well or not they’re just gonna push them through, then they don’t care themselves. Or they have absolutely no motivation to do anything at all. If we really are persuing what Dr. BeLue is suggesting, I think you can see the needle move a lot more. You’re treating the school system not as this place to park your kids during the day like as a warden, but you’re actually treating it as this system that could holistically help the students and help the children mitigate any trauma that they’re dealing with when they leave the walls of the school.

Alicia Barnes And I would add I think what I’m hearing and also the other piece of after you have your needs assessment, you know how to add the ACEs to the treatment, to the needs assessment, there’s the advocacy piece, so because some places are under-resourced but that doesn’t mean it has to continue to be under-resourced. I think that’s one of the powers of professional organizations because not only do you do the needs assessment, you can go back and feed into these are the policies that we need to work for based off of our needs assessment. This is a problem that’s been identified. And I think that in my work I’ve seen this a lot too. I also do advocacy as lawmakers aren’t always public health professionals. They’re not always physicians. Actually most frequently they are not, so that information and get trickling that down to the lawmakers and actually advocate for change that is evidence-based based off of data from our communities is an essential part of that changing those environments too.

Rhonda BeLue Even from a local perspective, I’m not sure that in terms of public health professionals in public health practice that some of the work that public health professionals do even gets to the school board. As public health professionals how do we create products and disseminate products that do go to those powers that be?

Maya Chilese Yeah. What I really am appreciating about this conversation is although we’re talking quite a bit about schools today specifically and ACEs in schools that you’re threading together the value of public health is being able to have a really holistic view of community and how we can fit into that. I think it feels a little bit like in today’s national environment it’s a great space for public health to say, hey we can help step into this advocacy role and help support policy conversations. And I particularly think at least maybe I’m mentioning this from my state’s experience, but what other data can we collect to help round out this conversation that we’re not doing now? We sort of defer to our partners to collect, you know our behavioral health partners might collect A, B or C, and recognizing that some of those datasets might be small or skewed. Things around ACEs are often collected around high-risk populations. I appreciate hearing a lot of recommendations for our public health professionals.

One thing I might sort of chime in before we move to some closing questions for us is just recognizing that particularly perhaps for local public health departments is that trauma-informed care can fit into a variety of places. This is what I’ve heard our speakers mention several times today that it isn’t this one program that you may or may not have money to initiate but that you can infuse the conversations around being trauma-informed in nearly everything you do. Perhaps you work at a clinic that provides WIC for families that you can infuse trauma-informed approach there. Perhaps public health professionals are working with businesses and worksite wellness that you can infuse trauma-informed care and thinking in those variety of settings.

I really appreciate hearing such a wealth of wisdom coming from you today. I want to just note there’s perhaps not a – there’s no way I can summarize everything that you shared today but just sort of a couple key highlights that I heard today. I might ask our speakers also just to do maybe a bit of a recap of the episode. And then I’ve got a couple last questions for you, but here’s some really powerful statements that I heard from you guys today. One, trauma-informed care really is for everyone. A trauma-informed approach is appropriate everywhere and public health has a role in helping us think about that and how we expand that and infuse that into things we may already be doing. Kemba, I really appreciated your participation today because it helps us think about an arena that public health is really big in from an obesity prevention perspective or an advocacy around physical health well that’s a space we’re already in so how do we marry those things together? You did a really wonderful job highlighting some of those things today.

I heard us talk about one in five people report over a lifetime having experienced at least one or more ACE and recognizing that that those statistics are particularly much higher when in regards to ethnicity or race so recognizing that there are some populations that are at higher risk for that. I heard some particular notes around we can do better to help increase awareness in general, but in regards to conversations around school settings, around teacher populations, coaching populations, and I think even you might say parent groups, right, so helping parents learn how to help other parents is a particularly valuable resource in school communities that might have lack of nurses available or other professional care services available.

I heard us talk about Public Health’s role in helping to do advocacy and policy and one thing that I think is a really powerful note that I heard from you guys today is just the recognition that toxic stress, trauma, crises, those things are very personalized. What might be traumatic experience to one might be different to another and therefore, it’s important for us to not box that in based upon how we might define that. It recognizes that can show up differently in both children and adults.

So I’m wondering if from the three of our experts today in our podcast what might you add as a wrap-up or just sort of a final few statements that can help recap the episode today?

Alicia Barnes Anyone could be an advocate or be an assistant to treating ACEs. I mean it starts with just asking the question, are there ACEs there? Is there toxic stress? Even if you miss that piece, if you’re able to sit with somebody or child and as they experience their toxic stress and be present with them that’s has a huge effect because at least you are addressing it even if you may not know what the toxic stress is. Sometimes with trauma it doesn’t come out or it’s inappropriate to ask what the specific trauma is. So just to be trauma-informed and be able to sit with some child as they’re going through adverse child experiences, or be a resource for them this front line every day helpful or in schools at homes and then in clinic settings.

Rhonda BeLue I would say that a trauma-informed approach needs to be infused just in the public health workforce starting from from the education of public health practitioners. I know that the MPH was the main public health professional degree but there’s a lot of bachelors in public health programs now. Infusing that from an early stage and making sure that our public health workforce comes out with an understanding of trauma-informed care, whether they end up working with children in schools or at their athletic venues or an after-school programs or any settings. We need to start infusing that training early on in our programs.

I will just say this is not evidence based and this is just my personal belief that psychiatrists and psychologists have to do this, but I also think that public health practitioners should do this before you start practicing and helping other folks to really go recognize your own trauma and to make sure that you’re taking care of yourself first. You can only take care of your community as well as you can take care of yourself. I think that there are a lot of adults and folks walking around who are public health practitioners who…we’ve all experienced trauma to some extent. We may not measure on the ACEs scale but everybody’s had their own life events. So really as a public health practitioner to have that reflective time whether that occurs in the classroom. I know that social work programs and other more site based programs do this, but as public health practitioners given what our kids and communities are going through these days with the help of internet and online bullying and what’s news and just access to information that can also be stressful, to really recognize your own trauma and your own stress and find healthy ways to cope with that as a public health professional, especially a lot of public health professionals work in places with a shoestring budget and the skeleton crew. How do you cope yourself so that you can be the best for those that you serve? Really it just definitely needs to be part of the public health workforce training.

Kemba Noel-London Yeah. I don’t think I can add anything, but I agree wholeheartedly with Dr. BeLue and Dr. Barnes especially with the process of really and truly understanding your own trauma because that becomes really important because the last thing that you want to do as a public health worker or you as a clinician is to go into the space and unintentionally traumatized or re-traumatize or re-victimize that child within your school. We want to help them. And we want to help anybody the best we know how, even if you’re not trauma-informed just that awareness on that cognition that I have to go into the space very open to just create that environment that they want to talk to you. Because like Dr. Barnes said just sitting with them and being present is helping, right, because a lot of the kids do gravitate to somebody who just genuinely do care about them so as a public health worker, even as a clinician, that’s something to just really be cognizant of, especially if you’re working in a school that does not have the best budget in the world. You want to help and you are not necessary trauma-informed, hopefully after hearing this you recognize that you can make a difference regardless if you get an official trauma-informed training or not.

Maya Chilese So perhaps here’s a final question and I’m reflecting on your statement around public health typically works on the shoestring budget with a skeleton crew but if time and resources were no issue what would you ideally like to see happen in this area?

Rhonda BeLue I would like to see definitely workforce training and a better public health infrastructure. I might be able to speak to some of those, Dr. Barnes, even trauma-informed design in public health facilities. Dr. Barnes has included me in a project on trauma and relaxation rooms for adolescents, but really putting some money into trauma-informed training, trauma-informed care, and especially for our health educators and for those that have that face-to-face contact with the community and front-line public health but also in trauma-informed design. How do you design a facility that helps reduce the trauma? Also, in your own workforce I think that we have trauma and our public health workforce and in the communities that we serve. I mean a child should have to have a pleasant visual and institutional experience, they shouldn’t have to wait to have that until they get extremely ill or required to go to a Children’s Hospital. That shouldn’t be the time where you get to go and have a nice facility to go receive care when you have a diagnosis that requires you to go to children’s speciality hospital. We should be able to provide that, you know, in our day-to-day organizations I would really like to see some more trauma-informed design.

Kemba Noel-London I think if we do trauma-informed design and that training becomes a train the trainer situation where public health officals are now trained in culture and creating a trauma-informed design. You can take that to school boards to help them revamp their schools in terms of just not only discipline but also in terms of the organizational layout. Something as simple as your classroom structures so when you have professional development before school starts with your teachers then it’s not just coming and decorating your classrooms, you’re actually working with the teachers to come out and create environments and a space that encourages learning. Also, it has desensitization and all those things built into that as well too.

Rhonda BeLue Not to mention that we’re talking about school-based settings, you also have layered on top of it children who have learning challenges or different learning styles and all the other numerous things that the teachers and the staff have to deal with?

Alicia Barnes So I would add that children belong in school and I think sometimes we get away from that model because children are getting suspended or expelled because of behavioral issues. And so if we had all of the resources I would say to have development of teachers, development of public health professionals as frontline to then have appropriate referrals and engaging mental health professionals for further levels of care because psychiatric illness deserves treatment, but a lot of times what comes to the clinic isn’t necessarily severe psychiatric illness. It’s the teachers that are unable to address the issues that are at hand or a social worker that are unable to have the resources they need to provide therapy services, even though they may or may not have been trained in those areas.

Kemba Noel-London I think if we can utilize the school-based health center model in terms of having that direct access to behavioral health as well as primary health as well too within the school system I think can also help as well too.

Rhonda BeLue To also engage, Kemba could close this out because her dissertation work is allied health including PT-OT athletic training and how to engage some of those other frontline practitioners with the public health workforce? We’re all working on the same issues so how I would also say there should be some more training and efforts if we have resources to break down some of the silos of all of these different individuals that are working with children and see the same children but see them in a disconnected and siloed way. Where as the child psychiatrist and athletic trainer and the public health professional may all be interacting with the child and have no idea that the other person is interacting with the child. How do we as public health practitioners really expand our scope and understand how we can work together with other allied health and other healthcare professionals to really put together a comprehensive model so that we’re not providing fragmented public health products and that we’re not reinventing the wheel or duplicating resources or missing out on resources that could go to children and families.

Alicia Barnes If there’s trauma-informed care training, if there’s psychological first aid training, how do you identify depression? How you identify anxiety? How do you refer when you get to that level where I need to see a child and adolescent psychiatrist? When is it to the level I need to see a therapist once a week? And so frontline training in that regard is essential. What I encounter is a lot of people people in the school systems that are welcoming that information because it’s not readily available. Moving to a systemic model that’s both trauma-informed care breaking down those silos is going to be central to that.

Rhonda BeLue And in terms of public health infrastructure you had mentioned earlier about WIC clinics. How do we make sure that our staff at WIC clinics that are often in public health facilities are under the purview of a county or local health department, sow do those staff recognize postpartum depression or depression or anxiety in children or in the moms or trauma in the mothers, or even the lactation specialists? How do we create trauma-informed WIC frontline staff and lactation specialists and all of those other public health workforce staff? How do we create a trauma-informed workforce in those areas as well? Really all areas I think it would be important even for those that are doing restaurant inspection should have some understanding of trauma-informed interviewing and trauma-informed care.

Maya Chilese If you reach a human this is an appropriate training for you, righ, if you interact with humans at all then become trauma-informed..to be thinking about how we can expand the awareness among those communities. What I was starting to say as I’ve long been an advocate for public health to help expand training around trauma-informed care to cosmetologist, nail technicians and barber, which are everyone’s therapists, you know. The things that definitely exist in communities where there’s clearly an absence of clinical psychologists as mentioned earlier.

This has been fantastic. I am all with the big vision of just give us all the money and we’re gonna help communities. I am with that. I heard the three, this has been such a great conversation, thank you so much. I heard the three of you talking about some really practical things that public health professionals and agencies and local public health can do. We certainly have talked about our big vision. I’m gonna add to that also one of the things that I would really love to see is the expansion of the use of community health workers and family peer support partners. I feel like that’s a population of professionals that can perhaps grow a lot quicker than the 30,000 child psychiatrists that are needed throughout the nation.

Let’s wrap this up a little bit so we know that our public health partners and professionals are listening today and sort of bringing back to our conversation or the point of our podcast today was around ACEs and ACEs in schools and thinking particularly about children. What might be the couple things that you would say to folks that are listening here when you hang up on the podcast today, what might be a couple concrete next steps or some recommendations for action that you would say to your colleagues?

Alicia Barnes It can start as easy as you’re going to pick your child up from school today and asking whether the teacher feels that they are properly trained to deal with trauma in the school system. Secondly, if you learn something writing a letter and sharing that with the school administrator or the local lawmaker. What are we doing as a community to implement this or address it? I think again going back to my other point if you see a child or know a child that maybe it’s going through a hard time to sit with them and just be there and see what the conversation unfolds to.

Rhonda BeLue I’ll piggyback on that a little bit. I know that there’s a lot of political discourse on a national level, but as public health professional know who your your local lawmakers are and know who your school board is. I think that’s the first step working locally in your own community and understanding the dynamics of where the money flows in your own community and having understanding of who’s on the school board, what the election cycle is, what the appointment cycle is, who your local office is the district office is, and who your local lawmakers are different depending on where you are. We’re in St Louis so we have a municipality for almost everybody to live in. We have a lot of municipalities and a lot of..we have a lot of local government here. Understand your local government, understand the tax structure, and really as a public health professional understand the dynamics of your city jurisdiction, county, and state. So you understand how to advocate and really what the issues are and where the power lies and how the money flows and I think that that’s an important exercise as a public health professional or public health student to really start with your own local community and to understand that.

Kemba Noel-London And I think with schools you as a parent or even if you work in say a particular school district, try to have understanding what the discipline policy is to see if they are moving towards a trauma-informed approach. I know within St. Louis there some schools that have gone towards restorative justice for discipline and those things. I think if you’re really trying to make a dent within like trauma-informed within school systems and ACEs within schools I think understanding what that discipline policy is and how exactly is that enforced. What does that actually look like? Because you can’t really make any substantial change if you don’t understand what’s actually going on within schools themselves. I think understanding what that policy is, talking with the school principal, and finding out what your resources are for trauma-informed training. Because within St. Louis we have Alive and Well, they do trauma-informed training you can be an ambassador to help reshape communities. There were a lot of resources as well, so I think figure out what resources you have within the realm of trauma-informed care where you are to start with giving that motivation and the knowledge and the language to really approach a different school to offer assistance. I’m not just saying tell them what they’re doing wrong, but also offer assistance to make a change within that one school. You never know it might piggy-back off to something else.

Alicia Barnes And the one thing we haven’t summarized too is to take care of yourself.

Rhonda BeLue Yes, self-care for the public health and health professions workforce is critical. I always give my students self-care lecture. I have a good friend who lives in Nashville who always says to her other friends take exquisitely good care of yourself. Her name is “Ola Ami?” so I will try to share to take really good care of yourself so that you can you can take care of others. And as a public health professional you may not have school-aged kids, so you may not think about the schools but the status of the schools is the status of your community, and the status of the future and those are the folks that are gonna be taking care of you when you’re old. So even if you don’t have a school-aged child go to a school board meeting, it’s your neighborhood, it’s your community and it’s the foundation of your community, it’s the next generation of the workforce. Even if you don’t have a school-age child really go and understand what’s going on in the school system and see how you can be involved and what are the public health implications because it’s your neighborhood schools, your community is no better than your neighborhood schools so really just go and understand what’s going on in your school system.

Maya Chilese Well that’s a really powerful sentiment. I mean just recognizing that the nurse who will be taking care of me when I’m 90 is in the elementary school a couple blocks away right now. Yeah that’s good. Ladies, this has been fantastic. I am so grateful that you’re willing to share your wisdom with us today. This is not only of course timely nationally, but it’s just so wonderful to have experts that understand public health, can help other public health professionals think about our role in this in helping to support social, emotional, and mental well-being. I like to use that phrase because it helps us think about what we want to have happen instead of, you know, how do we help address the problem of mental health? Well that’s not ours there’s a system for that, right. Our job is to help contribute to whole well-being. The phrase that we hear in behavioral health a lot is that there is no health without behavioral health, and since we’re in the lane of caring about the health of the public this is an important spot for us to think about.

So Dr. BeLue, Dr. Barnes, and the soon-to-be Dr. Noel-London I’m so grateful for your time today. Thank you so much for sharing your expertise for helping us not only learn a little bit more about ACEs in schools, but to help connect that to what we do every day as public health professionals and also just as members that care about our community so I really appreciate your time today. We’re grateful on behalf of the Midwestern Public Health Training Center for your contribution to this podcast series on mental health and thank you so much for your time.

Laurie Walkner Thank you for joining us today. Special thanks to our guests and to members of our planning committee: Sonja Armbruster, Katie Brandert, Stacey Coleman, Brandon Grimm, Joy Harris, Suzanne Hawley, Abigail Menke, Jeneane Moody, Melissa Richlen, Hannah Shultz, Laurie Walkner, and Kristen Wilson for guidance in creating this series. And to Maya Chilese for guidance as well as hosting this series. Theme music was composed and produced by Dave Hoing and Roger Hileman. Funding for this webinar is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript.