by Eiryn Renouard (Research Fellow) and Mason Burley, PhD (Director of Research)
Across the Inland Northwest, dozens of non-profit organizations and thousands of individuals work tirelessly to improve the lives of children and adults that may be struggling with addiction, chronic mental and physical health conditions, and economic insecurity. Community leaders, dedicated volunteers and generous donors want to contribute to effective solutions, but the problems often seem intractable and progress insufficient.
While there is not one simple solution to these issues, a common understanding of the underlying origins can guide community responses and help prioritize interventions. Today, an established body of scientific literature has demonstrated that early exposure to traumatic events can interfere with social and emotional development and lead to disruption that continues well into adulthood. Without addressing long-lasting trauma, programs that focus on poverty, substance abuse, health disparities and other problems may be well-meaning, but ultimately less effective. 
This brief discusses the impacts of adverse childhood experiences (ACES) and how trauma informed practices can mitigate and prevent negative outcomes for the most vulnerable members of our communities. We conclude with a series of steps that community organizations, coalitions and funders can take to develop trauma-informed solutions that can improve our response to persistent social problems.
Starting with ACES – Adverse Childhood Experiences
Research in the neurological and social sciences confirms that exposure to overwhelming stress during a child’s early years can leave a genetic ‘footprint’ that hinders development over the course of a lifespan. Trauma responses serve as a normal reaction to abnormal stress and occur when individuals have inadequate capacity to cope with external threats  Children are particularly vulnerable to this toxic stress. A landmark study conducted in 1998, identified ten ‘adverse childhood experiences’ that deeply impact a child’s ability to grow and develop properly: 
- Physical abuse
- Physical neglect
- Emotional abuse
- Emotional neglect
- Sexual abuse
- Parent incarceration
- Parental separation/divorce
- Parental mental health
- Parental substance abuse disorder
- Witnessing domestic violence
In the original Kaiser ACE study  12.5% of participants had 4 or more ACES, compared to 36% of participants with no ACES. An analysis of an ACES questionnaire on the Behavioral Risk Factor Surveillance System (BRFSS) administered in 23 states (between 2011-14) found that 15.8% of individuals had 4 or more ACES while 38.5% had no ACES. 
Left unaddressed, experiences from abuse, neglect and family dysfunction create powerful ripple effects that are felt by schools, criminal justice institutions, businesses, health systems and community structures. The effects of child maltreatment are felt over a lifetime, resulting in annual costs of over $401 billion in the United States.
These lifetime costs grow exponentially as the number of ACES experienced by an individual accumulate. Compared to persons with zero ACES, individuals with four or more ACES are:
- 12.2 times as likely to ever attempt suicide;
- 7.4 times as likely to consider themselves an alcoholic
- 4.7 times as likely to have ever used illicit drugs
- 4.6 times as likely to ever feel depressed for two or more weeks in a given year
- 3.9 times as likely to have chronic bronchitis or emphysema
- 2 times as likely to have had a stroke, heart disease or cancer
Another analysis of the 2010 BRFSS ACE module in ten states found that adults with 4 or more reported ACES were 2.3 times more likely to not complete high school or be currently unemployed.  The clear health and economic disparities seen in populations that experience childhood adversity are not temporary or isolated. The cyclical impacts occur when children of parents with early adverse experiences are raised in a similar fashion, increasing the risk of intergenerational poverty, abuse, and chronic health problems.
Community Risk Factors – Eastern Washington and North Idaho
While there are few data sources that report the prevalence of ACES at a local level, we can examine rates of related health conditions and behaviors in different regions. Regional differences in four outcomes are reported.
Between 2013 and 2017, there were 642 deaths by suicide in Spokane and Kootenai counties and 181 deaths by suicide in SE Washington and North Central Idaho (Whitman, Latah, Idaho, Clearwater, Nez Perce, and Asotin counties). Nez Perce and Asotin counties has an age-adjusted suicide death rate of 24 per 100,000 residents, compared to a rate of 19 per 100,000 residents in urban Spokane and Kootenai counties.
Rates of excessive drinking among adults (age 18+) varied between 14 and 20% across rural and urban counties. While there were six detox treatment facilities in Spokane and Kootenai counties, there were no licensed detox centers in rural counties in Southeast Washington and North Central Idaho.
Data on opioid misuse are difficult to track at a local level. The availability of opioids, however, provides an indication of how prescription drug misuse may impact communities. The map below displays the total number of Medicare/Medicaid opioid prescriptions in 2017 by zip code. In both urban and rural locations, there were zip codes with over 15,000 opioid claims – representing over 10% of prescription drug claims. Unfortunately, in this region, there were only two facilities with opioid treatment services, according to the Substance Abuse Mental Health Services Administration (SAMHSA).
In the Spokane/Kootenai county region, about one out of six Medicare beneficiaries had a diagnosis for depression in 2015. The prevalence for depression was similar in larger towns (like Clarkston/Lewiston), but slightly lower in the neighboring rural counties. The rates reported here include both Medicare recipients over age 65 and ‘dually-eligible’ beneficiaries under age 65 with disabilities that qualify for Medicare and Medicaid.
Addressing ACES through Resiliency Training
The prevalence of challenges related to ACES show in the maps above raise questions about what steps can be taken to reduce the long-term effects of early childhood trauma. Just as adverse experiences in childhood increase risk of developmental harm, practices that reinforce childhood resiliency can promote positive youth development and lessen the lasting impacts of trauma. A range of social/environmental factors influence the development of resilience and shape an individual’s response to stress. Dr. Kenneth Ginsberg, a pediatrician specializing in adolescent medicine, identified “7 Cs” that serve as building blocks of resilience: Competence, Confidence, Connection, Character, Contribution, Coping, and Control. Parents and professionals serving children can review a list of questions about these building blocks to begin developing a resilience-based practice.
Children growing up in communities should receive guidance on how to experience an array of emotions – such as joy, sorrow, happiness, and pain – with confidence and proper perspective. A resilient child can handle adversities with well-developed coping skills. In addition, the skills essential to resiliency training – such as increasing predictability and focusing on consistent, trusted relationships – are not just relevant to parenting or youth development, but support effective collaborations for service providers, business leaders, educators and other community members. Fostering trauma-informed and resilient communities is a universal strategy that can improve outcomes across sectors such as healthcare, education and criminal justice.
Trauma-Informed Community Strategies
Funding groups and non-profit organizations can play an important role in testing and promoting holistic, trauma-informed responses to the most difficult community challenges.
- Support organizations and initiatives that adopt trauma-informed principles (safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, cultural, historical, and
- Review and select appropriate trauma-informed treatments and interventions. The National Child Traumatic Stress Network maintains a current database of evidence-based practices.
- Leverage cross-sector relationships (non-profits, academia, government, and business) to increase awareness of science behind adverse childhood experiences and facilitate adoption of trauma-informed initiatives
- Collect screening and monitoring data on impact of trauma in various settings, including schools, social service organizations and health care clinics.
Case Studies: Kitsap Strong
Kitsap Strong is a local example of an organization that has found success in addressing trauma at the community level. In the early 2000’s, the Washington State Family Policy Council, along with the Kitsap County Health and Safety Network, brought together leaders from various organizations and developed a strategic plan for how to spread the Search Institute’s Developmental Asset Model of Positive Child and Youth Development across the county. The initiative grew, raised funding for programs to build resiliency, and increased community engagement. The initiative led to reduced child abuse and neglect referrals, fewer youth reports of substance abuse, decreased juvenile arrests, fewer weapons in school, and improved academic performance and graduation rates. One of Kitsap Strong’s projects is the Collaborative Learning Academy (CLA). The CLA funds 11 collaborative partnerships, that educate community residents and organizations how health and brain development are affected by trauma, and different techniques and strategies that can build resilience and promote healthy youth development.
Trauma-Informed Care in Eastern Washington and North Idaho
There are a number of organizations throughout the inland northwest that provide training, education and resources to help organizations integrated trauma-informed practices.
- The Child and Family Research Unit (CAFRU) is an extension of Washington State University that “promote(s) health and wellness for underserved and at-risk populations through research, education and community development.” Several CAFRU-led initiatives support professional development, education and training on trauma-informed practices: They are also involved in helping communities develop their capacity to provide supportive services to their residents, and they deliver training in complex trauma to over 30,000 professionals.
- The LC Valley Resilience Coalition (LCVRC) includes organizations throughout the greater Lewiston (ID)-Clarkston (WA) region that collectively organize speakers, workshops and trainings to address the impact of adverse childhood experiences and promote resilience-building strategies.
- Fostering Change Washington works to create a statewide foster care system where the foster parent community is empowered, supported and recognized as partners, creating a solid foundation where children can thrive. Fostering Change Washington offers trauma-informed care workshops that provide parents and guardians with the tools needed to parent a child with trauma.
- Fostering Resilient Learners consulting group provides training and coaching focused on childhood trauma and strategies to improve learning and develop childhood resilience.
- Community Resilience Initiative (CRI) is a collaborative campaign based in Walla Walla valley (WA) that supports community efforts to reduce the impact of ACES and promote the resilience of children. CRI provides trauma-informed trainings, community resources/research and sponsorship of an annual conference dedicated to building a unified community response to effects of childhood trauma.
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 Merrick, M.T., Ford, D.C., Ports, K. A., Guinn, A. S. (2018). Prevalence of Adverse Childhood Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA Pediatrics, 172(11), 1038-1044.
 Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A., & Ford, D. C. (2017). Adverse childhood experiences and life opportunities: Shifting the narrative. Children and Youth Services Review, 72, 141-149.