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One state. One year. (Partial) Cost of ACEs = $5.2 billion.

Jane Stevens ·
In looking at the impact of childhood trauma, you can’t get much clearer than this: In 2017, ACEs among Tennessee adults led to an estimated $5.2 billion in direct medical costs and lost productivity from employees missing work. That’s just one year, according to the new report, “ The Economic Cost of ACEs in Tennessee ," released on Feb. 1, 2019 by The Sycamore Institute in Nashville, Tenn. And to provide some perspective, $5.2 billion is one-seventh of the state’s annual budget . This $5.2...
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Overview of the Community Resiliency Model, used worldwide to help trauma survivors re-regulate their central nervous system, offered in two, free 90-minute webinars.

Carey Sipp ·
Elaine Miller Karas , key creator of the Community Resiliency Model (CRM), will be joined by CRM trainers from Wilmington, NC, Allison Wine , behavioral specialist, and Kelly Purcell , instructional coach and multi-tiered support specialist for this free, two-part training. Register now for two, FREE 90-minute sessions May 7 from 11 a.m. - 12:30 p.m. EST and May 14 from 11 a.m. - 12:30 p.m. EST (The complete overview requires attendance at both sessions. Registration link below registers you...
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Parent Handouts updated and available In Dari, English & Spanish

Christine Cissy White ·
The updated parent handouts are now available in Spanish as well as English and Dari. Here's the blog post with links to all three versions of each flyer. All versions of the Understanding ACEs and Parenting to Prevent & Heal ACEs parent handouts can be downloaded, distributed, and used freely. Both flyers were made with generous support from Family Hui, a Program of Lead for Tomorrow, who is responsible for making the Spanish and Dari translations available. These are updates of the...
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Population-Based Analysis of Temporal Trends in the Prevalence of Depressed Mood Among Sexual Minority and Heterosexual Youths From 1999 Through 2017 [jamanetwork.com]

By Alexandra H. Bettis, Richard T. Liu, Jama Pediatrics, October 21, 2019 Depression in adolescence is highly prevalent and associated with negative long-term outcomes.1 Despite decades of research on treatment for adolescent depression, sexual minority youths remain a particularly at-risk group.2 Temporal trends inform progress in addressing the need to eliminate health disparities among sexual minority populations.3 To our knowledge, this study presents the first population-representative...
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Preventable trauma in childhood costs north America and Europe US$ 1.3 trillion a year [WHO]

Karen Clemmer ·
By World Health Organization (photo by WHO/Malin Bring) The findings of a new study on the life-course health consequences and associated annual costs of adverse childhood experiences (ACEs) show that preventable trauma in childhood costs north America and the European Region US$ 1.3 trillion a year. The article, published in the Lancet and co-authored by Dinesh Sethi and Jonathon Passmore, Programme Manager, Violence and Injury Prevention, WHO/Europe, looks at the legacy of ACEs and their...
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Primary Care & Telehealth Strategies for Addressing the Secondary Health Impacts of COVID-19

From ACEs Aware, May 13, 2020 This webinar will focus on building understanding and identifying primary care and telehealth strategies and tools to address the secondary health effects of the COVID-19 emergency. Widespread stress and anxiety regarding COVID-19, compounded by the economic distress due to lost wages, employment and financial assets; mass school closures; and necessary physical distancing measures can result in an increase of stress-related health conditions. These secondary...
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School Nurses Share Their Voices, Trauma, and Solutions by Sounding the Alarm on Gun Violence [link.springer.com]

By Robin Cogan, Donna M. Nickitas, Donna Mazyck, Sunny G. Howell, Springer Link, November 22, 2019 Abstract Purpose of Review The purpose of this review is to discuss the impact of gun violence within schools from the perspective of school nurses. School nurses are first responders whose skills are crucial to ensuring the health and safety of students, staff, and faculty within schools and the surrounding community. Recent Findings In the USA, fear has long dictated how schools invest their...
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Screening for ACEs in Pediatric Practice [American Academy of Pediatrics - CA Chapter 2]

By Ariane Marie-Mitchell, American Academy of Pediatrics, October 2019 In the August newsletter, we provided an overview of the definition and impact of adverse childhood experiences (ACEs) (http://aapca2.org/aces). In this article, we will explore the argument in favor of screening for ACEs in pediatric practice, and describe the process and results of a California state advisory group on screening for trauma. The American Academy of Pediatrics (AAP) recommended screening for toxic stress...
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Sheltering in Place: ACEs-Informed Tips for Self-Care During a Pandemic

Jim Hickman ·
Millions of lives have been affected in unprecedented ways by the Coronavirus (COVID-19). We are all grappling with uncertainty—our daily routines interrupted, not knowing what is to come. For those of us who have Adverse Childhood Experiences (ACEs), these times can be particularly distressing. At the Center for Youth Wellness (CYW), we know that childhood trauma can have a significant impact on an individual’s health and well-being – both physiologically and psychologically. Since the...
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Suicides among nurses are on the rise. Here's why one of America's fastest-growing jobs is facing a major crisis. (businessinsider.com)

Researchers from the University of California at San Diego recently conducted what they said is the first nationwide investigation into nurse suicides in more than 20 years. They found that both male and female nurses had higher rates of suicide than men and women in the US . The findings are consistent with the increasing rates of suicide across the country. The US suicide rate has risen in recent years, increasing by 28% in the past two decades , to the highest it's been since World War II...
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The Center for Youth Wellness Launches Childhood Adversity Screening Program with Leading North Carolina Health Systems [PR Newswire]

Jim Hickman ·
Charlotte pilot program with Atrium Health and Novant Health supports state's goal to address social, economic and environmental health to improve child and family health outcomes The Center for Youth Wellness (CYW) announced it is partnering with two leading U.S. health systems in the Southeast to launch a screening program on childhood adversity. CYW's National Pediatric Practice Community (NPPC) has done on-site training at the headquarters of Atrium Health and Novant Health in Charlotte,...
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The Impact of Childhood Adversity on Health and COVID-19 [acpm.org]

By Kevin Sherin, American College of Preventive Medicine, May 7, 2020 There is a growing dialog about COVID-19 and its impacts on childhood adversity (ACEs), chronic stress, and mental health across the lifespan. The fear and social isolation associated with COVID-19 commonly exacerbates existing chronic stresses. Reports are surfacing of increased mental health problems, anxiety, partner violence, depression, suicidality, child abuse, opioid use disorder, other substance abuse, drug...
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The Link Between Childhood Trauma and Sexual Abuse in Adulthood

ana joanes ·
Please check out our latest Healing Our Ghosts' podcast with ECHO's executive director and #metoo Harvey Weinstein's silence breaker Louise Godbold. Healing Our Ghosts shines light into the suffering we keep hidden. We are not alone in our struggles and when we share our pain, we lift the shame secrecy that keeps us alone and disconnected from each other and prevents us from healing. With humor and compassion, Ana Joanes interviews a wide variety of guests about their messy lives, how they...
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The Relentless School Nurse: ACEs Impact Nurses More Than We Realized!

Robin M Cogan ·
I ran across this message on www.acesconnection.com and not only did it catch my attention, but it also made me want to dig deeper. Could it be true that nurses have a higher ACEs score than other healthcare professionals? It seemed true in this small survey, but was this a representation of a trend? If it was, the implications in nursing practice could be tremendous and concerning. What I found was that there is a grand canyon gap in research. The minimal studies that do exist confirm that...
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The Relentless School Nurse: When the Health Office Pass Includes Emotions

Robin M Cogan ·
The collaboration between school counselors and school nurses creates safe spaces for students at school. Building a coalition between school counselors and school nurses creates a safety net for our most complex and challenging students while benefiting the whole school community. Promoting connections through intentional relationship building, and ensuring a school environment that is physically, emotionally and psychologically safe changes the culture and climate. Read about an amazing...
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TIC: News and Notes for November 2019

Scott A Webb ·
ACEs, Adversity's Impact Podcast: Dr. Nadine Burke Harris Vital Signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention - 25 states, 2015-2017 Animal study shows how stress and mother's abuse affects infant brain LGBTQ, traumatized homeless youth more vulnerable to being trafficked: Report How do these pediatricians do ACEs screening?Early adopters tell all When family relationships become toxic: The trauma of...
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TIC: News and Notes for the Week of October 21, 2019 [dhs.wisconsin.gov]

Scott A Webb ·
ACEs, Adversity's Impact There is only one boat: The myth of normalcy by Dr. Gabor Mate Understanding historical trauma to strengthen community Childhood trauma linked to early, premarital childbirth and poor health for women Early life racial discrimination linked to depression, accelerated aging When mothers are killed by their partners, children often become 'forgotten' victims. It's time they were given a voice Children's language skills may be harmed by social hardship Does racism...
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Tools and how to use them is focus of second webinar on Community Resiliency Model, May 14, 2020

Carey Sipp ·
The second of two free Community Resiliency (CRM) webinars with Elaine Miller-Karas , key creator of the CRM, will be held Thursday, May 14, from 11 a.m. - 12:30 p.m. ET, (10 a.m. CT; 9 a.m. MT, and 8 a.m. PT) and will include the practical application of tools of the model. CRM is an ACEs science-based biological model for helping individuals become emotionally regulated during natural disasters and other dysregulating times. Miller-Karas will be joined by CRM trainers from Wilmington, NC:...
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University of Florida Graduate Public Health Course: Trauma-Informed Approaches for Individuals, Communities, and Public Health: Student Project Summaries

Lindsey King ·
The University of Florida College of Public Health and Health Professions partnered with Peace4Tarpon under the Robert Wood Johnson Mobilizing Action for Resilient Communities (MARC) grant. Together they created 2 online graduate courses that focus on addressing ACEs and creating trauma-informed and resilience-based programs from a public health approach. Peace4Gainesville and Peace4 TheBigBend have also contributed to these courses. This post is intended to showcase some of the work of the...
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Webinar: Cultivating Our Best Selves in Response to COVID-19 | Tuesday, March 17 at Noon PDT

Elaine Miller Karas ·
How to use the skills of the Community Resiliency Model (CRM) for self and others to be the calm in the storm as we face the unknown. Free Webinar Tuesday, March 17 at Noon PDT Speakers: Elaine Miller-Karas, LCSW Linda Grabbe, PhD, FNP-BC, PMHNP-BC Zoom Webinar Registration Link: https://zoom.us/j/715837300 Additional ways to join are listed at the bottom of this post. About the webinar leaders: Elaine Miller-Karas is the Executive Director and co-founder of the Trauma Resource Institute and...
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Webinar: The Human Impact of Climate Change

Alison Cebulla ·
The Community Resiliency Model Disaster Relief Program Climate change emergencies are real and the human toll during and in the aftermath impact children, teens and adults. This webinar will hear from Kelly Doty, a survivor, who lost her home in Paradise and is working in a community-based program to help the children and their parents in the aftermath. Elaine Miller-Karas, the key developer of the Community Resiliency Model Disaster Relief Program, will explain the program and how it helps...
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When Hidden Grief Gets Triggered During COVID-19 Confinement

Tian Dayton ·
first published by The Meadows 4/15/20 Our sense of loss during the current COVID-19 crisis can trigger hidden emotions from when we experienced a sense of loss before. Whatever early losses you have had in your life — whether they be your own divorce, your parents, or both, or the abandonment of one parent, a childhood or parental illness or death, financial upheaval, constant moving around, or growing up with parental addiction or adverse childhood experiences (ACEs) — they are likely to...
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World Premiere: Stress & Resilience: How Toxic Stress Affects Us, and What We Can Do About It [developingchild.harvard.edu]

By Center on the Developing Child, Harvard University, November 13, 2019 When the stress in your life just doesn’t let up, and it feels like you have no support to get through the day—let alone do everything you need to do to be the best parent you can be—it can seem like there’s nothing that can make it better. But there are resources that can help, and this kind of stress—known as “toxic stress”—doesn’t have to define your life. In this video, learn more about what toxic stress is, how it...
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Young adults with PTSD may have a higher risk of stroke in middle age (UNC Healthcare)

Karen Clemmer ·
Lindsey Rosman, Ph.D., assistant professor in the division of cardiology, is the lead author of the study, the story was published on Oct 17, 2019, for UNC Healthcare and UNC School of Medicine. CHAPEL HILL, N.C. — Oct. 17, 2019 — Young adults who suffer from posttraumatic stress disorder (PTSD) may be more likely to experience a transient ischemic attack (TIA) or major stroke event by middle age, raising the risk as much as other better-known risk factors , according to new research...
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12 Things I Wish My Doctor Understood About Childhood Trauma

Anna Runkle ·
It doesn’t happen that often anymore, but one place where I almost always get triggered with my Childhood PTSD symptoms is when I visit the doctor. I could never even put this into words before. But now that I’m mostly healed from my Childhood PTSD symptoms, I want to express what I wish my doctors – all the doctors of my life – had understood about the effects of Childhood trauma, about me. Note: This is one of my most personal posts ever. Unless you’re someone who really prefers text, I...
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7 Ways to Help a Child Deal with Traumatic Stress

Hilary Jacobs Hendel ·
Traumatic stress feels awful. Thankfully, there are small things we can all do to help relax a hyperaroused nervous system.
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9 New Communities Join ACEs Connection

Christine Cissy White ·
ACEs Connection Hawai'i Hawai'i is a place of natural beauty, multicultural heritages and practicing cultural arts that provides wellness and healing. However, cultural, historical & generational trauma has lead to an imbalance in our ahupua'a or ecosystem. Join us as we educate, empower & celebrate wellness and resilience building in our communities using trauma and culture aware strategies. Mahalo Community Manager: @Daniel Goya Northeast Region Hawaii Carey's
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ACEs & African Americans Community on ACEs Connection

ACEs Connection envisions a resilient world where ALL people thrive. We are an anti-racist organization committed to the pursuit of social justice. In our work to promote resilience and prevent and mitigate ACEs, we intentionally embrace and uplift people who have historically not had a seat at the table. ACEs Connection celebrates the voices and tells the stories of people who have been barred from decision-making and who have shouldered the burden of systemic and economic oppression as the...
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ACEs Research Corner — November 2019

Harise Stein ·
[Editor's note: Dr. Harise Stein at Stanford University edits a web site -- abuseresearch.info -- that focuses on the health effects of abuse, and includes research articles on ACEs. Every month, she's posting the summaries of the abstracts and links to research articles that address only ACEs. Thank you, Harise!! -- Jane Stevens] Jackson DB, Chilton M, Johnson KR, Vaughn MG. Adverse Childhood Experiences and Household Food Insecurity. Am J Prev Med. 2019 Nov;57(5):667-674. PMID: 31522923...
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Action needed today by trauma advocates to urge Congress to address mental health and trauma in current COVID-19 legislation

The follow is a message from Dan Press, Legal Advisor to the Campaign for Trauma-Informed Policy and Practice ), about the need to contact Congress regarding a COVID 19 funding bill being considered this weekend. He is urging ACEs science/trauma advocates and leaders to send emails to their U.S. Senators and Representatives immediately to address the mental health and trauma implications of this pandemic. All – I hate to bother you on a Sunday, but we urgently need you to contact Congress to...
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Announcing Trauma and Resilience Competencies for Nursing Education

Kathleen Wheeler ·
The authors are pleased to announce the Trauma and Resilience Competencies for Nursing Education. These competencies serve as a guideline of minimal expectations and reflect essential knowledge, skills and behaviors for three levels of nursing education: 1) undergraduate, 2) graduate, and 3) psychiatric nurse practitioner programs. The Trauma and Resilience Competencies, developed in 2018 at the Egan School of Nursing and Health Studies at Fairfield University in Connecticut by an Expert...
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California unveils ACEs Aware initiative to screen for trauma

Laurie Udesky ·
Will screening for adverse childhood experiences (ACEs) in California be mandatory? No, but it’s recommended. Will there be training for physicians and staff on how to screen? Yes. Who will be reimbursed for screening patients in California? Physicians who serve patients in the state’s Medi-Cal program — for now. For more answers to these and other questions that surfaced during a Dec. 4 webinar introducing Californians to a new statewide initiative, read on. Come January 1, California will...
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Cancer as a survivor

Christine Cissy White ·
Many people use the phrase CPTSD to stand for PTSD from complex trauma. To me, C-PTSD means cancer and PTSD. I have cancer and I’m a trauma survivor. I’m a survivor with cancer but not yet a cancer survivor. Will I be a survivor squared?
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CenteringParenting Recognized as Innovative Pediatric Intervention in New Report from The Center for the Study of Social Policy [globenewswire.com]

By Vandana Devgan, Centering Healthcare Institute, November 15, 2019 Centering Healthcare Institute (CHI) is honored to share that its pediatric group care model CenteringParenting®, has been recognized by The Center for the Study of Social Policy (CSSP) as an innovative pediatric intervention in its latest study. "Fostering Social and Emotional Health: Common Threads to Transform Everyday Practice and System" , released as part of the Pediatrics Supporting Parents (PSP) initiative, shares...
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COVID-19 and Healthcare worker's families: behind the scenes of frontline response [thelancet.com]

By Amine Souadka, Hajar Essangri, Amine Benkabbou, et al., EClinical Medicine, May 17, 2020 During the COVID-19 outbreak, healthcare professionals are exposed to a high-risk of infection and mental health problems, but also fear of contagion and spreading the virus to their families. In fact, considering them as individuals implies looking beyond their function as frontline responders and taking into account their societal role as parents, spouses and offspring. While work-family balance is...
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CPTSD and Social Awkwardness: Another Source of Isolation

Anna Runkle ·
For those of us who grew up with abuse and neglect at home, it can be hard to know how to ACT in social situations. Here's an example.... Have you ever been to a hotel where there is a person who is there to carry your bags, and even though you didn’t ask, they carry your bags to the room and it’s totally awkward, and you think “I’m supposed to give them a tip, right? I’ve, like seen this on TV. But you don’t have cash, and they’re just standing there ," and you think, "What do I do? What do...
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Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic [jamanetwork.com]

By Abby R. Rosenberg, JAMA Pediatrics, April 14, 2020 Coronavirus disease 2019 (COVID-19) is affecting our health care community in unprecedented ways. As a pediatric oncologist who studies resilience in the context of illness, I started thinking about what this pandemic means for our professional resilience a few weeks ago, when the first US patient with fatal COVID-19 died in my home city of Seattle, Washington. Promoting resilience among health care workers and organizations starts with...
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Did you know you can post a blog on ACEs Connection?

Did you know you can post a blog on ACEs Connection? Have you been wanting to share a news article? Tell us your story? Explain what you're doing in the ACEs world? Look below for videos & link to blog posts on how to post a blog! Plus, videos on how to add photos, documents, and videos to your blog post. Please leave questions or comments below! How-To: Post a Blog Add a How-To: Add a Title Image to your Blog Post How-To: Insert a Video into a Blog Post How-To: Add a Document to a Blog...
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Donna Jackson Nakazawa on bringing down the stress-threat response

Christine Cissy White ·
Cissy's note: Donna Jackson Nakazawa has graciously allowed me to cross-post some of her current and future Facebook page posts here in the Practicing Resilience for Self-Care and Healing community on ACEs Connection . Hello Friends. As a SciComm journalist with 30 years of reporting and 6 books under my belt, which focus on how our stress response governs our immune health, I’ve been thinking about what I have learned, and how I might help you quiet your body and mind during this # pandemic...
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Doulas & Covid-19: A toolkit for doulas (DONA International)

Karen Clemmer ·
Please the attached toolkit for more information. From the toolkit: Best practices when working with clients Given how new this virus is, we currently have very little data on how it might affect pregnant people and newborns. Guidelines from the CDC outline recommendations for how to support pregnant and laboring people with Coronavirus. (3) There is currently no evidence that the virus is spread from mother to baby in utero, or that it is transmitted in human milk. (4)
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Dr. Nadine Burke Harris (podcast) [armchairexpertpod.com]

By Dax Shepard, Armchair Expert, October 10, 2019 Nadine Burke Harris is an American pediatrician who is the 1st and current Surgeon General of California. She is known for her work in adverse childhood experiences. Nadine visits the Armchair Expert to discuss the impact childhood trauma has on health and longevity, she talks about her own experience with childhood adversity and she gives tools to buffer those who have many ACEs. Nadine talks about the screening process she pioneered and Dax...
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Dr. Vincent J. Felitti, M.D. has been recognized with the Albert Einstein Award of Medicine by the International Association of Who’s Who [kentuckyreports.com]

By Kentucky Reports, November 9, 2019 Dr. Vincent J. Felitti has over 50 years of experience in the field of Internal Medicine with extensive knowledge in the areas of childhood trauma, the genetic disease Hemochromatosis, and obesity. Serving as a Clinical Professor of Medicine at the University of California since 1982, Dr. Felitti’s knowledge and experience is broad and significantly biopsychosocial. Dr. Felitti achieved his Medical Degree from Johns Hopkins in 1962 after being inspired...
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During COVID-19: The need for your skills. Self-care resources. Share your TI responses? Thank you!

Mimi graham ·
Dear Trauma F riends and C olleagues: The COVID 19 pandemic offers a critical opportunity to share your unique skills in coping with stress and trauma. Many of us and the families we serve may be shifting through the stages of change and grief----denial, anger, bargaining, acceptance---about this pandemic. You may be adjusting to telehealth and virtual visits but know that our families need your reassurance and help in regulating and coping. Hope you’re all practicing self-care while you...
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Emotional Well-Being and Coping During COVID-19 [psychiatry.ucsf.edu]

From Weill Institute for Neurosciences, UCSF, May 2020 These are unprecedented times. We need to work extra hard to manage our emotions well. Expect to have a lot of mixed feelings. Naturally we feel anxiety, and maybe waves of panic, particularly when seeing new headlines. A recent article by stress scientist and Vice Chair of Adult Psychology Elissa Epel, PhD, outlines the psychology behind the COVID-19 panic response and how we can try to make the best of this situation. Our anxiety is...
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Forsyth County Trauma Informed Care Network

Laneita Williamson ·
The Forsyth County Trauma Informed Network is taking great strides into recognizing and addressing community post Covid-19 impacts. PowerPoint attached.
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From Trauma-Informed to Asset-Informed Care in Early Childhood [brookings.edu]

By Ellen Galinsky, Brookings Institute, October 23, 2019 The focus on “toxic stress,” ACEs (Adverse Childhood Experiences), and trauma-informed care have been game-changers in the field of early childhood development. They have helped us recognize the symptoms of trauma, provide appropriate assistance to children, and understand that prolonged adversity in the absence of nurturing relationships can derail a child’s healthy development. Just look at the media’s and the public’s reaction to...
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GABOR MATÉ JOINS EP. 3 on May 21 with Darrell Hammond and Filmmaker Michelle Esrick. [crackedupmovie.com]

CRACKED UP THE EVOLVING CONVERSATION TRAUMA AS THE ROOT CAUSE OF ADDICTION With DARRELL HAMMOND DIRECTOR MICHELLE ESRICK and RENOWNED TRAUMA AND ADDICTION EXPERT GABOR MATÉ, M.D. author of In the Realm of Hungry Ghosts: Close Encounters With Addiction MODERATED BY JANE STEVENS, FOUNDER OF ACES CONNECTION Hosted by ACES Connection Thursday May 21st at 2pm PDT / 3p MT / 4p CT / 5pm EDT FREE FOR ALL WHO REGISTER! IF YOU REGISTER, BUT CAN NOT ATTEND, YOU WILL RECEIVE A RECORDING WITHIN ONE WEEK.
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Got time for a little brainstorming with ACEsConnection?

Jane Stevens ·
On Friday, March 20, 2020, you're invited to join me to talk about how we, as a community, can continue to guide and educate ourselves about to deal with the effects of the spread of Covid-19, and how to continue those efforts with people who don't yet know about ACEs science. And, given this last week, how we can provide more support to stay in the front of our brains instead of feeding our amygdala.
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Governor Cuomo’s Cancer Research Initiative Disappointing. No ACES included.

Peter Chiavetta ·
I attended the presentation of Governor Cuomo's Cancer Research Initiative at the Buffalo Science Museum October 22, 2019. Brad Hutton Deputy Health Commissioner State of NY presented. Erie County Health Commissioners in attendance. It had all the data on the 4 major cancers in the East Side of Buffalo, NY. https://www.health.ny.gov/diseases/cancer/cancer_research_initiative/docs/erie_presentation.pdf I'm all excited. Prepared with 2 dozen ACE handouts. Sat quietly for the 45 minute power...
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Home Gun Safety Queries in Well-Child Visits [jamanetwork.com]

By Carole H. Stipelman, Greg Stoddard, Kyle Bata, et al., JAMA Pediatrics, October 28, 2019 Firearms are a leading cause of death in US children, and the rate of suicide by firearms in people aged 10 to 19 years has increased since 2008.1 In the United States, 4.6 million children (approximately 7%) live in households with at least 1 gun that is stored loaded and unlocked.2 Safe storage of guns and ammunition may decrease the occurrence of self-inflicted or unintentional firearm injury to...
 
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