Adverse Childhood Experiences Among H omeless C hildren in the Fragile Families and Child Wellbeing Survey

1. Adverse Childhood Experiences Among Homeless Children in the Fragile Families and Child Wellbeing Survey National Association for the Education of Homeless Children & Youth Conference November 3, 2013 Elizabeth Ezratty, Policy Associate

2. Learning Objectives • Understand the implications of adverse childhood experiences (ACEs) on lifelong health, risk taking behaviors, and mental wellbeing • Understand the prevalence of neglect, abuse, and family dysfunction in homeless, at risk, and stably housed children’s lives • Present policy initiatives that reduce adverse childhood experience exposures and identify children most at risk of childhood trauma

3. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

4. Stress & Child Development The National Scientific Council on the Developing Child at Harvard University distinguishes 3 types of stress: • Positive: experiences that are part of every day life and cause brief and moderate physiological stress responses (immunizations, meeting a new person). • Tolerable: non-normative experiences that are intense but bearable due to the presence of a supportive adult (death of a loved one, traumatic event or accident). • Toxic: intense, frequent, and uncontrollable experiences during which a child lacks the support of a caring adult (child abuse or neglect). Can result in an altered physiological response to stress and diminished brain development.

5. Reproduced with permission from: Robert F. Anda, and Vincent J. Felitti, Centers for Disease Control and Kaiser Permanente. http://acestudy.org/ace_score

6. Adverse Childhood Experiences Study • Collaborative effort between the Centers for Disease Control and Kaiser Permanente in San Diego • Retrospective study in the 1990’s involving more than 17,000 adults • Explored relationship between experiencesthrough 18 years old and adult health and wellbeing • Respondents could have a possible ACE score of between 0 and 10 representing the number of ACEs experienced through 18 years old. • 54% of respondents were women, average age was 57, 74% were white, 36% attended some college, and 50% were college graduates

7. Adverse Childhood Experiences Study

8. Adverse Childhood Experiences Study Findings Source: Adverse Childhood Experiences Study and the Centers for Disease Control and Violence Prevention.

9. Connection between ACEs and Health & Behavior Outcomes 1= no additional risk Source: Adverse Childhood Experiences Study and the Centers for Disease Control and Violence Prevention.

10. Life Expectancy of people with 0 & 6+ ACEs 0 ACEs 80 Years 60 Years 6+ ACEs Source: Adverse Childhood Experiences Study and the Centers for Disease Control and Violence Prevention.

11. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

12. The Behavioral Risk Factor Surveillance System (BRFSS) • Largest health and behavior surveillance system in the world • Implemented in all 50 states and territories through State Departments of Health • ACE module has been implemented in 22 states thus far • Excludes questions on neglect

13. Prevalence of ACEs in 5 State BRFSS Data from: Arkansas Louisiana New Mexico Tennessee Washington Source: Centers for Disease Control and Prevention, “Adverse Childhood Experiences Reported by Adults – Five States, 2009,” Morbidity and Mortality Weekly Vol. 59, no. 49 (2010).

14. Risk of Health & Behavior Outcomes in Minnesota BRFSS 1 = no additional risk Source: Minnesota Department of Health, Adverse Childhood Experiences in Minnesota: Findings & Recommendations Based on the 2011 Minnesota Behavioral Risk Factor Surveillance System, January 2013.

15. Risk of Adult Health & Behavior Outcomes in Washington BRFSS 1 = no additional risk Source: Source: Andaand Brown, Adverse Childhood Experiences and Population Health in Washington: The Face of a Chronic PublicHealth Disaster, Results from the 2009 Behavioral Risk Factor Surveillance System (BRFSS), July 2, 2010.

16. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

17. Fragile Families and Child Wellbeing Survey Background • Birth cohort longitudinal dataset • Children born between 1998-2000 • Five waves: birth, age 1, 3, 5 & 9 • Data collected in 20 large (pop > 200,000) U.S. cities • Nationally representative of births between 1998-2000 in large U.S. urban centers • Detailed variables at each wave • Demographics • Family composition • Labor market behavior • Fertility • Relationships • Health & well-being • Housing status • Parenting practices • Disciplinary approaches Fragile Families Sample Cities

18. Here’s what we did: • If any one of the questions that comprised an ACE indicator was answered then a family was included • Likely under-represents ACEs • Surveys and in-home assessments analyzed for ACE indicators based on the original ACE survey • ACE indicators constructed from multiple questions in each wave • Not every question is asked each year • Respondents are caregivers • Likely under-represents ACEs • A total of 2,410 families were included

19. Here’s what we did: • Questions cover the first 9 years of the subject child’s life • Questions were included if they inquired about the subject child’s experiences of abuse or neglect, or the presence of family dysfunction in the home • Used the BRFSS as guidance on how to define “often or very often” • May under or over-represent ACEs

20. Frequencies used • Emotional Abuse: • “swore or cursed at” 3 or more times in the last year • “shouted, yelled, screamed, swore, or cursed” a few times a week • Called the child “dumb or lazy” or some other similar name 6or more times in the last year • Emotional Neglect: • “said you would send child away/kick out of the house” 6 or more times in past year • “you're caught up with own problems-not able to show love to child” 6 or more times in past year • Physical Abuse: • hit the child “on the bottom with a belt” or similar object or hit the child “with a hard object like a brush” on the bottom 3or more times in the last year • slapped the child on the “leg, arm or hand” 11 or more times in the last year • Any questions related to spanking were excluded

21. Housing Status definitions • Ever homeless or doubled upincludes families that lived in shelters or other places not meant for human habitation or were living doubled up with family or friends but not paying rent • Ever at risk includes families reported having troubles paying essential bills such as rent or mortgage, phone, or utilities, that they moved more than twice in the last year, or had ever been evicted • Always stably housedincludes families who reported none of these issues

22. Fragile Families Demographics Housing Status: Mother’s Education at baseline Ever Homeless/Doubled up: 27% <HS: 28% At Risk of homelessness: 40% HS/GED: 31% Always stably housed: 33% Some College/Technical School: 19% Mother’s Race/Ethnicity:College/Graduate School: 22% Black: 24% Mother’s Relationship at Baseline: White: 35%Single: 20% Hispanic: 33%Cohabitated: 21% Other: 9%Married: 59% Mom’s Mean Age at birth of focal child (baseline): 27 years old

23. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

24. Cumulative Number of ACEs in Fragile Families 0 ACEs 1 ACE

25. Individual ACE-indicators in Fragile Families * * * * Constructed from fewer questions in Fragile Families

26. Number of Cumulative ACEs by Housing Status

27. Presence of Child Maltreatment by Housing Status

28. Presence of Household Dysfunction by Housing Status

29. Inter-relatedness of childhood traumas

30. Summary • ACEs are common for children in Fragile Families • Housing status is associated with differential levels of ACEs • ACEs are inter-related

31. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

32. Poverty and ACEs in Fragile Families • Split group into Poor (below 130% of federal poverty line) and Not Poor (above 130% of FPL) • $24,817 for a family of 3 in 2012-2013 • Ensures that comparisons between groups reflect differences in housing status rather than poverty • Total number of families in Poor subsample is 1,103

33. Homelessness among Poor and Not Poor Children

34. Number of ACEs among Poor and Not Poor Children

35. Individual ACEs among Poor Children in Fragile Families * * Constructed from fewer questions in Fragile Families

36. Number of Cumulative ACEs by Housing Status among Poor Children

37. Presence of Maltreatment among Poor Children

38. Presence of Household Dysfunction by Housing Status among Poor Children

39. Limitations • Fragile Families questions were not the same as ACE survey • ACE indicators constructed from multiple questions • Not all ACE indicators were asked in every year • Original ACE survey questions ask if maltreatment occurred “often” or “very often” • Most Fragile Families questions are directed to a caregiver rather than the child

40. Summary • Poor children experience more ACEs than those who are Not Poor • Poor homeless and doubled up children experience more cumulative ACEs than other housing groups • Differential rates of household dysfunction, abuse, and neglect exist between housing categories • Questions cover the first 9 years of life • Results are conservative

41. Presentation overview • Explain the Adverse Childhood Experiences Study and adverse childhood experiences (ACE) framework • Ongoing ACE research through Behavioral Risk Factor Surveillance System • Introduce Fragile Families and Child Wellbeing Survey (Fragile Families) and ICPH research approach • Present and explain the prevalence of ACEs among children in Fragile Families • Present and explain the prevalence of ACEs among Fragile Families after controlling for poverty • Discuss policies and approaches that buffer against ACEs

42. Prevention Approaches • Parental Engagement • Home Visiting programs • Early Childhood Education • School Based Health Centers

43. Parental Engagement Home Visiting Programs • Send qualified professionals to visit expecting parents or parents with children up to age five • This professional could be a nurse, a social worker, a counselor, or a culturally competent peer community member • Teach skills that promote positive child-parent relationships and improved child and maternal health and wellbeing

44. Home Visiting Evidence • Home Visiting programs impact: • Increased birth spacing • Child health • Parental self-sufficiency • Reduced incidence of abuse and neglect reports • Improved positive parenting techniques Source: Olds et. al, “Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial,” JAMA (1997); Duggan et. al., “Evaluation of Hawaii’s Healthy Start program,” Future of Children, (1999); U.S. DHHS, Home Visiting Evidence of Effectiveness; New York State Office of Children and Family Services, Bureau of Evaluation and Research, Healthy Families New York: Reflections, 2011.

45. Barriers for homeless families & providers • Home visitors struggled with family transience and programs often operate using geographic zones • Staff possessed limited knowledge of the homeless system • Staff were not adequately trained to deal with families in crisis • Strict program guidelines leave little or no option to conduct meetings in public spaces • Low levels of parent engagement • Privacy issues with families who double up Source: CarieBires, Heartland Alliance, FACT Project, Heartland Health Outreach, Partnering to Serve Homeless Children, Presented at the National Alliance to End Homelessness Conference, February 2013.

46. Parental EngagementEarly Childhood Education • Parent engagement or positive experiences in high quality early childhood education can moderate many negative child behavior and cognitive outcomes from: • Domestic violence • Having a household member in prison • Maternal depression • Substance use Source: Administration for Children and Families, US DHHS, Head Start FACES 2000: A Whole-Child Perspective on Program Performance, Fourth Progress Report, (2003).

47. Barriers for homeless families • Waiting lists • Family transience • Cost • Poor outreach and awareness • Transportation difficulties • Time

48. Barriers for service providers • Lack of trust of and fatigue with social services • Child absenteeism • Parent involvement • Evaluation compliance

49. Parent Engagement Promising Initiatives • Washington • authorized parent participation in voluntary home visiting programs, Head Start or other parent child development activities, or volunteering at their child’s day care, pre-school, or school to count as part of a parent’s TANF mandatory work requirements • Massachusetts • parenting workshops fulfill the activity requirement to receive a subsidy under the Child Care and Development Fund • Maryland • Since 2002, all four year olds living at or below 185 percent of the federal poverty thresholdare entitled to early learning services • Montgomery County created “parent academies” for all student families • Oklahoma • Since 1998, every 4-year-old in Oklahoma gets free access to a year of high-quality pre-k.

50. School Based Health Centers • School based health centers: • Improve access to medical care • Improve access to mental health counseling • increased use of hormonal birth control • Increased use of mental health services Source: Soleimanpouret.al., “The Role of School Health Centers in Health Care Access and Client Outcomes,” American Journal of Public Health, (2010); Ethieret.al., “School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students,” Journal of Adolescent Health, (2011).