Northeast Florida 
ACE Alliance 

Northeast Florida 
ACE Alliance 
(NFAA)
Strategic Plan

To address the single greatest under-addressed public health threat facing our nation today

May 2022

Table of Contents

NFAA Strategic Plan Overview4
What are ACEs?6
The Link Between ACEs and Health: Toxic Stress7
What Is Resilience?8
The NFAA Framework9
The NFAA Framework Diagram10
STAGE 1: PROMOTE UNDERSTANDING AND EDUCATION………………..11
STAGE 2: ACTIVATE AND TAKE ACTION15
STAGE 3: KEEP THE MOMENTUM19
NEXT STEPS20
ACKNOWLEDGEMENTS20
APPENDIX A: Partners in this plan21
APPENDIX B: Additional ACEs Science and Research Findings24
APPENDIX C: Outreach Presentation Feedback………………………………..26

2

NFAA acknowledges the effects of Adverse Childhood Experiences (ACEs) in our communities and is taking steps to prevent and heal trauma

NFAA STRATEGIC PLAN OVERVIEW

In 2022 the North Florida Ace Alliance began strategic planning as a multi-organizational collaborative to address and identify priority issues and areas through a collective action to address, educate, mitigate, and heal those affected by ACEs and toxic stress. The core strategies include: 
	Education
Education and barriers to educational attainment as a priority issue to be addressed by NFAA, outlining specific strategies to ensure that Adverse Childhood Experiences (ACEs) are understood, prioritized, and addressed in schools, universities, daycare, and any educational institutions or community organization where learning take place; and

Creating and transforming schools and universities towards a trauma sensitive education model

Building trauma-sensitive schools involves changes to school policy, practice, and culture and requires ongoing efforts to ensure that all students—including students affected by trauma—are experiencing social, emotional, and educational success  

	Provider Screening
Encouraging providers to screen for ACEs and adopt Trauma-Informed Care within healthcare systems, primary care providers, pediatric practices, and other provides who would see at risk clients.

	Conduct an ACEs Public Awareness Campaigns 
NFAA to gather State and local data to determine priority populations for strategic communications campaign; and 

NFAA to maintain Paces Connection web space, a virtual learning community for ongoing stakeholder education and collaboration between trauma-informed/ healing-centered organizations across the area
	Begin Community-Driven Policy and Funding Priorities 
NFAA to conduct a review of ACEs prevention and healing services throughout 23 counties in Northeast Florida and subsequently develop a need assessment: and 

NFAA to encourage public and private partners to create OR 

increase the number and quality of trauma-informed/healing-centered programs available to individuals most impacted by ACEs; and

NFAA to establish and develop funding sources and sustainable revenue sources that directly support NFAA’s mission and stakeholder initiatives and programs 

	Provide Cross-Sector ACEs Training 
In concert with organizations across northeast Florida, NFAA will provide ACEs trainings and to prioritize ACEs training for community members, including resources for parents, community leaders, educators, law enforcement officers, and primary health and mental health providers; and
 
to work with stakeholders and community members to identify the next most appropriate population(s) for ACEs training, building on existing statewide and local efforts and resources. 

Vision, Mission & Guiding Principles

The vision of the NFAA Strategic Plan for Northeast Florida is to work to create resilient communities that work together to prevent and heal trauma. 

The mission/goal The Northeast Florida Ace Alliance, NFAA, strives to create a better world for our children, families, and communities by working together across sectors to prevent and address the impact of ACEs and toxic stress.

To meet this goal NFAA has developed three guiding principles:

1.	Promote understanding through training, education, and awareness and offer strategies to create consistent messaging for implementing and continuing this work throughout Northeast Florida.
2.	Discover and develop evidence-based strategies to prevent and heal trauma.
3.	Cite ways to regularly acknowledge those who champion trauma-informed work and resilience-building to further motivate and continue the work.

NFAA intends to use this plan as a guide to provide knowledge and understanding, training and education, and pathways to heal and mitigate ACEs and toxic stress throughout Northeast Florida. Participation in the plan development by individuals across sectors in the community will ensure that the plan provides diverse evidence-based strategies and practices to meet the needs of agencies and organizations looking to increase resilience in Northeast Florida.

WHAT ARE ACEs?

ACEs is an acronym for Adverse Childhood Experiences, which is the title of a 1998 study examining the relationship between childhood trauma and long-term health outcomes. One of the lead investigators, Dr. Vincent Felitti, had access to health outcomes data for patients at Kaiser Permanente San Diego, and he collaborated with Center for Disease Control researcher, Dr. Robert Anda, to survey the patient sample about their exposure to childhood trauma.1

The research revealed that exposure to ten childhood traumas directly impacted patients’ health outcomes. These ten traumatic experiences, which the researchers termed “Adverse Childhood Experiences,” are:

o	Physical abuse
o	Sexual abuse
o	Emotional abuse
o	Physical neglect
o	Emotional neglect
o	Intimate partner violence
o	Substance abuse
o	Mental illness in the household
o	Loss of parent through death, parental separation, or divorce
o	Incarceration of a household member.

•	While research and practice have long indicated that trauma has an effect on our health risk behaviors, and thereby impacts our social and behavioral outcomes, what the ACEs study revealed is that there is a clear, direct link between childhood trauma and adult onset of chronic disease. 

•	Not only is there a direct link between childhood trauma and health outcomes, but these outcomes are also dose-dependent; the more adverse childhood experiences that a person has been exposed to, the higher the risk of medical, mental health and social problems as an adult.

People with an ACE score of four or more are:

●	Two times as likely to have ischemic heart disease, cancers, and stroke
●	Three times as likely to have emphysema or chronic bronchitis
●	Four times as likely to experience clinical depression
●	Twelve times as likely to have attempted suicide
●	Seven times more likely to be alcoholic
●	Ten times as likely to have used intravenous drugs.

Jane Stevens, founder of ACEsConnection.com notes, “We have seen that childhood adversity contributes to most of our major chronic health, mental health, economic health and social health issues.”

Additional research and data on ACEs can be found in Appendix B

THE LINK BETWEEN ACEs AND HEALTH: TOXIC STRESS

Subsequent research has identified the mechanisms that lead to these poor health outcomes. The Harvard Center for the Developing Child uses the term “toxic stress” to describe how the body’s stress response system becomes activated in ways that are harmful for the developing body and brain of children.

Normal or positive stress is anxiety associated with everyday experiences like getting frustrated or getting shots at the doctors. Toxic stress is extreme or frequent stress which does not let up. Toxic stress increases exposure to adrenaline and cortisol, and increases blood pressure, cholesterol, and glucose levels, all of which weaken the circulatory and immune systems. These direct physical processes are the foundation leading to many long- term chronic diseases.2

POSITIVE STRESS	
TOLERABLE STRESS	
TOXIC STRESS	
Mild/moderate and short-	More severe stress	Extreme, frequent, or extended	
lived stress response	response but limited in	activation of the body’s stress	
necessary for healthy	duration which allows for	response without the buffering	
development	recovery	presence of a supportive adult	

Intense, prolonged, repeated and unaddressed Social-emotional buffering, parental resilience, early detection, and/or effective intervention

Normal stress is a part of a child’s healthy development. However, toxic stress is not. And, if left unaddressed, toxic stress can negatively affect a developing body and brain by disrupting learning, behavior, immunity, growth, and even the way genes are read and transcribed.

Research has identified early interventions that focus on the child, the caretaker and the environment will help to strengthen resilience factors and can help to minimize a toxic stress response. The implications for improved health outcomes are clear. Given the potential impact on health outcomes and overall community well-being, it is important that every community explore ways to build resilience for individuals, families, and communities as a whole.

Communities around the country have started “ACEs initiatives” to identify strategies that can increase trauma-informed and resilience-building practices. Critical to the success of these plans, is to work across all sectors in the community: healthcare, social service agencies, businesses, community-based organizations, schools, and more—creating resilience-building opportunities for all children as well as for the adults that support them.

WHAT IS RESILIENCE?

According to Weiland et al., resiliency is defined as “the ability for flexible adaptation of psychological control functions appropriate to local context” or “the ability to modulate impulses, affect expression, and behavior to adapt to environment context”.4 While Alim et al., described resiliency as the “absence of psychopathology despite exposure to high stress.5 Simply, resilience is the ability to successfully adapt to hardships, such as traumatic experiences. Its strong evidence-base has shown that those with high resiliency have a lower prevalence of behavioral disparities.4
Resiliency allows for flexibility of thinking and problem solving during high-stress situations and can stop individuals from making stress-induced decisions, such as under peer pressure, which could lead to adverse consequences.5 Resilience is not something we are born with; it is a skill which can be learned and applied to everyday life. Building resilience refers to both activities that directly impact physical stress response, such as healthy sleep habits, and resources in the environment that mitigate stress, such as supportive individuals. 

.

THE NFAA FRAMEWORK

Promote Understanding and Education

Activate and Take Action

Keep the Momentum

The NFAA Framework is based on the ACEs Connection organizing model, Growing Resilient Communities, which captures the common stages characteristic of successful ACEs initiatives.

This organizing model suggests first steps, as well as momentum building steps, that highlight how local ACEs initiatives can structure and organize themselves for success. The NFAA framework model focuses on three stages to aid NFAA County in becoming a Resilient community:

Stage 1: Promote Understanding and Education
Stage 2: Activate and Take Action
Stage 3: Keep the Momentum

This strategic plan includes strategies at each stage that are aimed at promoting action at many levels, including by individuals, agencies, and throughout the community. Additional strategies may be identified as NFAA continues to implement and receive feedback on the plan.

Strategies are not in any priority order and may be used independently or in combination, as appropriate. NFAA will be closer to its vision of being a resilient community as more community partners work together to implement more strategies to prevent and heal trauma.

Examples of how strategies in the framework be used at different levels of the community: 

Individuals: Relationships are a critical protective factor and can play a significant role in helping children cope with challenges. The healthier the relationship a child has with at least one caring individual, the more likely he or she is able to recover from trauma and thrive.

Agencies: Agencies can adopt trauma-informed practices by committing to changing the practices, policies, and culture of an entire organization. This type of change requires staff at all levels and in all roles to modify their activities based on an understanding of the impact of trauma and the specific needs of trauma survivors.

Community: Community can be defined as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or social settings. When individuals in the community have experienced trauma, leaders from diverse sectors such as state and local government, non- profit, parent and youth advocates, private business, and philanthropy can help by collaborating and building partnerships to change the outcomes for individuals in the community.

 Bridging across sectors in the community will increase chances of creating relationships and individuals accessing support within the community that they need to heal, which then can improve public health and well-being.

THE NFAA FRAMEWORK

Strategies include:
1.	Acknowledge ACE Champions
2.	Gather and Incorporate Additional Feedback
3.	Evaluate Progress
4.	Hold Events that Celebrate the Progress of the County
5.	Ensure Wellness of People Providing Trauma-Informed Services

Strategies include:
1.	Identify and Capitalize on Existing Trauma-Informed Resilience Work in the County
2.	Identify and Join Leadership Teams
3.	Create Action Plans and Commitment Steps by Sector
4.	Integrate Protective Factors
5.	Peer to Peer Support Networks
6.	Advocate for Policy Change
7.	Universal Workforce Training
8.	Incorporate Trauma-Informed Care in Contracts, Programs, & Services
9.	Target Areas of Inequity
10.	Consider Screening for ACEs

Stage 2: Activate and Take Action

Strategies include:

Stage 1: Promote Understanding and Education

1.	Education Programs and Workshops
2.	Community-wide Trainings
3.	Utilize Toolkits
4.	Utilize Websites to Share Information
5.	Community Presentations and Conversations
6.	Film Screenings
7.	Identify ACE Champions

Stage 3: Keep the Momentum

**Strategies may be used independently or in combination by individuals, agencies, or communities

Promote Understanding and Education

STAGE 1: PROMOTE UNDERSTANDING AND EDUCATION
This stage focuses on increasing community education to raise awareness of ACEs and their effects, as well as creating a common language for everyone in Northeast Florida. Strategies to consider include:

1.	Education
Trauma changes the architecture of a developing child’s brain and physiology. These changes impair academic efforts. They affect children’s memory systems, their ability to think, to organize multiple priorities (executive function)—in other words their ability to learn, particularly literacy skills. Furthermore, changes in a child’s neurobiology often result in a student having difficulty in regulating his/her emotions and reading social cues, which in turn compromise their ability to pay attention, follow directions, work with teachers, and make friends with other students.3 

ACEs are often the root cause of serious learning disabilities, health problems, social challenges and behavioral problems that impact a child’s ability to learn. For educators, students who have experienced multiple adversities (20%-50% of all students) can be more difficult to engage consistently, require additional supports and often need more attention thus reducing instructional time for other students. With many students and their families experiencing adversity, schools may face an uphill challenge in addressing them without local partner services and supports from the larger community and other systems. Caring relationships and safe and supportive environments help prevent and mitigate the consequences of ACEs. 

NFAA’s education efforts will be focused around:
•	Educate ourselves and others to understand ACEs and resilience. We can educate ourselves to understand the impact of adverse childhood experiences (ACEs) and resilience (the ability to thrive, adapt and cope despite tough and stressful times). We know that the presence of a caring, stable adult at school and being raised in a safe, stable, and nurturing environment are two critical factors to build resilience. We know that resilience is a skill that can be taught, learned and practiced. We all can become resilient with the right training and people around us. Resilience isn’t just for children; adults can also learn these skills. 
•	Second, advocate for more state and local resources to fund and conduct trainings and workshops for educators who work with children with high ACE scores. 
•	Third, advocate for trauma-informed training for all school staff and for implementing trauma-informed district-wide policies and programs. Talk to our school board members and state legislators. Tell them how our public schools can and must play a critical role in helping children. For many children, school is the only safe and stable place in their lives. Children are more likely to get needed mental health services at school than through any other source. Teachers and other educators have a role to play but they can’t do it all. As community members we must also be allies for children with high ACE scores. 

ACEs and Resilience: What Can We Do? 
What strategies help promote Resilience? Here are a few strategies you can use to help to build resilience or mitigate the effect of ACES, to help educate communities and encourage local leaders to take action. (Adapted from the Facilitator’s Guide to Resilience by Prevent Child Abuse/KPJR Films.) 
Strategy: Changing the discussion from “what’s wrong with you?” to “what happened to you?” Neuroscience research shows how the brain is constructed through an ongoing process that begins prenatally and continues into our twenties. While ACEs undermine this development and negatively affect the foundation of the brain, resilience can help repair these structural problems and allow a person to “bounce back” from the trauma or adversity they had experienced. The ACEs study shows how changing the conversation when a child is acting out from “what’s wrong with you” to “what happened to you and how can we help fix it?” is a powerful tool. The presence of compassionate teachers, caring coaches, or other adult mentors can help build resilience. 
Strategy: Recognizing systemic racism contributes to toxic stress. While the results of the original Resilience study were groundbreaking, and incredibly valuable, many racial justice advocates have noted the research tended to focus on middle class, college-educated, white populations. Looking at Resilience with a racial equity lens is also necessary to fully understand the impacts or systemic racism in regard to childhood trauma.
Strategy: Recognizing toxic stress as the largest public health issue of our generation. ACEs can have long-term effects on our bodies and lifelong health. When we equip our children and families with the tools, they need to overcome ACEs, we can reduce the costs that future generations incur for health care. Eliminating toxic stress among children would profoundly impact on the health and well-being of individuals and entire populations and lower health care costs. 
Strategy: Building critical collaborations: The consequences of ACEs cuts across professional disciplines, personal relationships, and all socioeconomic demographics. Creating trauma-informed agencies and disciplines to work in collaboration will give us a better chance of improving child and family well-being overall. 
Strategy: Promoting safe, stable, nurturing relationships & environments: Caring adults and stable environments are necessary for a child’s healthy development and for building resilience. Safe, stable, nurturing relationships between children and their parents or caregivers act to buffer the effects of toxic stress and other ACEs. If parents are struggling, other adults – like teachers or coaches – can be present to provide the safe, stable, nurturing relationships that a child need. PTAs can also invest in supporting and promoting policies and providing programs that strengthen families. 
Strategy: Preventing intergenerational transmission of toxic stress: To create good outcomes for children we need to support adults. Resilience makes very clear the inter-generational effects associated with ACEs and trauma. What a parent teaches their children will get passed on to their children’s children. We need businesses, churches and synagogues, PTAs and other civic organization and community advocates to work together on programs to support families who are dealing with trauma that impacts children. 
Strategy: Promoting hope: If you watched the film Resilience, you heard one clear message – there is always hope! Science shows the effects of ACEs do not have to be permanent. Different disciplines, agencies and people can come together and make a difference in the lives of trauma- impacted children. Get educated and then get involved in helping our children and our community be stronger and healthier. 

2.	Workforce Development
Along with educating ourselves and advocacy efforts, we also want to provide trainings and educate staff from organizations that work with people who may have been exposed to ACEs. Trainings would be focused around helping these organizations and their staff understand how their encounters with clients are impacted by trauma. 
Trainings would focus on the following objectives: 

i.	 Increase understanding and awareness of the impact of trauma
ii.	 Develop trauma-informed responses
iii.	 Provide strategies for developing and implementing trauma-informed policies

Trauma-informed care can be defined as adjusting organizational practices in ways that help decrease exposure to toxic stress for community members seeking services, as well as care that boosts community members’ ability to recover from adversity.

The suggested training should be provided and tailored to a wide-range of audiences, such as school districts, faith-based organizations, first responders, higher education institutions, and direct service providers in the County. Our hope is that through this type of development we will have a stronger, better-informed workforce to support future generations of persons with ACES. 

3.	Utilize Toolkits & Media
Toolkits & Media highlighting trauma-informed practice and resilience building strategies, can be a great source of information to find examples of how to change practice. For example, the Community Resilience Cookbook (http://communityresiliencecookbook.org/) highlights several communities that have implemented Resilience efforts and shares their stories and tools for others.

Other toolkits that share information on trauma informed practices and resilience include:

Building Community Resilience Toolkit, Volume 1 Strategies 2.0 http://strategiesca.org/resources/

Trauma Informed Care and Practices
National Center for Trauma Informed Care http://www.samhsa.gov/nctic/ National Child Traumatic Stress Network https://www.nctsn.org/

A Trauma Sensitive Toolkit for Caregivers of Children
Spokane Regional Health District https://srhd.org/1-2-3-care-toolkit

a.	Websites
Websites can be used as a resource that can share local information, provide updates to the community on local trainings and events, and be used as a communication tool.
Currently https://www.cdc.gov/violenceprevention/aces/resources.html provides general information on ACEs and links to ACEs resources.
In addition, the NFAA Community Page at PACEs Connection https://www.pacesconnection.com/g/northeast-fl can serve as a source for planning, resources, and creating a common calendar of events focused on ACEs, trauma-informed practices, and resilience.

b.	Community Presentations and Conversations
Many people in Northeast Florida have not learned about ACEs, trauma-informed practice, and resilience. NFAA will work to develop educational materials and presentations which can be share in the communities we serve.
The Community Coalition Alliance currently hosts a collaborative training and technical assistance series for community coalitions and their partners in the Northeast Region of Florida each Tuesday at 2pm. This platform could be utilized to host virtual meetings to inform coalitions and their partners on ACEs and influencing factors. These meetings are recorded and shared via the CCA YouTube page and could also be share to the NFAA Community Page at PACEs Connection.
c.	Film Screenings
Begin screening events featuring the film Resilience: The Biology of Stress & The Science of Hope, as well as other relevant films. The film Resilience sheds light on how toxic stress can trigger hormones that negatively impact the development of brains and bodies of children, putting them at greater risk for disease, homelessness, prison time and early death. 
Resilience also chronicles the dawn of a movement that is determined to create action to combat ACEs and their effects. The target population for the film Resilience is adults such as parents, healthcare providers, education providers and other agencies across sectors.

Other films that could be screened to increase awareness and understanding of ACEs include:

o	Paper Tigers--This film targets at-risk teens and offers valuable insight into the hearts and minds of teens pushing back against the specter of a hard childhood.
o	Broken Places--The film Broken Places targets the adult population and explores why some children are severely impacted by early adversity while others are able to thrive. This film also gives a better understanding of the devastating impact of childhood adversity as well as the inspiring characteristics of resilience.

Sharing the Resilience: The Biology of Stress & The Science of Hope film and other suggested films with organizations and agencies in Northeast Florida is an extremely effective engagement tool and has motivated agencies to consider organizational change. 

The films may also be used with the community as an engagement tool to promote conversation, as they utilize common language and identify simple action steps.
d.	Identify NFAA Champions
ACEs initiatives stall without a steady source of energy. ACEs efforts in Northeast Florida will be identified and championed and acknowledged to further the message. Champions can be identified by city, neighborhood, sector, or organization. Some counties thrive with one or two. 
A few champions identified within a county helps to accelerate the growth pace of ACEs initiatives.

STAGE 2: ACTIVATE AND TAKE ACTION

Activate and Take Action

This stage focuses on those who are familiar with ACEs and are ready take action to prevent and heal trauma.

Strategies to be considered include:
1	Identify and Capitalize on Existing Trauma Informed Resilience Work in Northeast Florida

Sharing this information among NFAA County residents and professionals helps the community and community members recognize their existing strengths as a resilient community, as well as expands trauma informed practices throughout the County.
2	Identify and Join Leadership Teams
Continued momentum needs backbone support to nudge the initiative forward over time. Many ACEs initiatives have stalled after an initial energetic start. Strong, stable ACEs initiatives benefit from a steering committee to set goals, and most importantly, review progress regularly in order to avoid getting “stuck.”

The impacts of ACEs affect an entire community, it is vital to have representation in an ACEs initiative, across the life-span, with a cross-sectoral scope. Having a steering committee in place provides a starting point for ensuring that all sectors are at the table, providing input and support for sustainability. 
3	Create Action Plans and Commitment Steps by Sectors
Different sectors, such as education, law enforcement, healthcare, government, and community-based providers, all have a role to play in addressing ACEs. Each sector may need to address ACEs using different strategies. It is important for each sector to have a relevant work plan to help increase knowledge of ACEs, utilization of trauma informed care, and the building of resilience within every aspect of the community.

For example, a brief work plan for the education sector would include goals, objectives, and measures, such as increasing parents’ awareness and knowledge about ACEs, having teachers know where to refer families for resources, training administrators in trauma informed care, and supporting resilience for children. Then specific school districts would be able to gauge where they are on a work plan specific to education and identify their next steps.

Should the sector wish to measure its impact, setting change targets can be a valuable way to ensure work plans are successfully accomplished. Change targets should be specific and achievable. For example, school districts might have a change target of ensuring 80% of parents are knowledgeable about ACEs. This can be measurable by an annual parent survey.

4	Integrate Protective Factors
The Center for the Study of Social Policy has identified five protective factors that increase family strengths, enhance child development, and reduce the likelihood of child abuse and neglect. The five protective factors are:
o	Parental resilience
o	Social connections
o	Knowledge of parenting and child development
o	Concrete support in times of need
o	Social and emotional competence of children.
Further research on families shows that interventions using the protective factors can disrupt cycles of childhood trauma, prevent traumatic experiences for children, and help parents to heal their own trauma.

These protective factors can be integrated into many day-to-day practices at the individual, agency, or community levels.6
6 The Center for the Study of Social Policy Strengthening Families A Protective Factors Framework, (2018). 
   Retrieved from https://cssp.org/wp-content/uploads/2018/11/About-Strengthening-Families.pdf

5	Peer-to-Peer Support Network
The goal of a peer-to-peer support network is to have individuals with the understanding or lived experience have peer support relationships with trauma survivors. Establishing a peer-to-peer support network will allow individuals, and/or families who have experienced ACEs to receive the emotional support they may need and also may allow the individual or family to benefit from:
o	Sharing information and advice
o	Increasing social network, friendship & reconnection
o	Becoming empowered
o	Finding hope and positive role models
o	Achieving insight
o	Learning coping skills
o	Reducing symptoms.

Models of peer support networks include parent cafes, peer navigators, and youth peer mediation, grandparent support groups and other peer support groups.

6	Advocate for Policy Change
Policy changes at the state, county, city, and organizational levels can highlight that becoming trauma-informed and resilient are NFAA priorities.

Other ACEs initiatives in other communities have advocated for official resolutions or proclamations to be incorporated by city and county government, which serve to raise awareness while also signaling that ACEs awareness and resilience are priorities. Examples of ACEs initiatives:

•	California- https://acestoohigh.com/2014/06/17/california-assembly-health- committee-approves-aces-resolution-by-16-0-vote/#more-3224
•	Utah- https://acestoohigh.com/2017/04/02/utah-gov-gary-herbert-signs- resolution-to-encourage-state-policies-and-programs-based-on-aces- science/#more-6744
7	Target Areas of Inequity
Unfortunately, as common with many indicators of well-being, ACEs do not affect the population equally and certain populations experience them more frequently. For example, children in high crime neighborhoods may experience ACEs related to violence at a higher rate than children living in low crime neighborhoods. In addition, some recent ACEs research has looked into the ways that institutional racism has similar effects to the initial ten ACEs identified.5

Targeting strategies toward populations who experience inequity in indicators of health and well-being can assist in ensuring resources go to those who are most in need in our community. However, if targeting a specific population or community, it is important to look at any unintentional consequences this may have and ensure it is not creating additional inequity.

By addressing the root causes of structural inequities in our society, these efforts can have an impact on lowering the rate of ACEs and increasing resilience.

8	Screening for ACEs
There are screening tools for ACEs, as well as assessment tools which have ACEs and trauma screening integrated within the questions. Screening can assist with early identification and intervention, along with assisting in understand of individuals’ behaviors. While screening for ACEs can be an important strategy, it should be considered among many strategies and may not be necessary or appropriate for all types of organizations or institutions.

Examples of screening and assessment tools are below:

•	ACEs screening tool for children and adolescents https://centerforyouthwellness.org/cyw-aceq/
•	Parental ACEs screening tool
https://www.aap.org/en-us/Documents/resilience_ace_screening_parents.pdf
•	Resilience Questionnaire
https://www.aap.org/en-us/_layouts/15/WopiFrame.aspx?sourcedoc=/en- us/Documents/RESILIENCE_Questionnaire-1.docx&action=default
•	Pediatric Intake Form http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_intake form.pdf

While screening for ACEs may seem an obvious first action, it is important to consider the readiness of an organization or program to screen for ACEs. Prior to implementing screening include education and training on:
•	Understanding the target population and the goal (e.g. are you screening the parent for whether their child has ACEs or are you screening the parent for their ACEs?)
•	Trauma-informed practices
•	How to administer the screening, as well as interpret and discuss the results, and appropriately refer families
•	Screening should be truly integrated into practices and protocols, not just another form to fill out
•	Trauma informed treatment practices should be offered and/or available through linkage for those identified with ACEs

In NFAA, collecting data on ACEs may be used to inform decision-making about ACEs, trauma, and resilience. When looked at in aggregate, the data could be useful in developing programs and activities appropriate for different population.

Keep the Momentum

STAGE 3: KEEP THE MOMENTUM
This stage focuses on ways to continue the hard work and keep people from becoming discouraged. 
Strategies to be considered include:
1	Acknowledge NFAA County Champions
There are many approaches to acknowledging NFAA ACEs champions, from featuring them on web and outreach materials, to providing certificates at a regional event.
2	Gather and Incorporate Additional Feedback
Gather and incorporate additional feedback for strengthening the Resilience NFAA Strategic Plan. The Plan should be a living document which grows and changes over time as NFAA becomes a more resilient community. Feedback forms can be developed and then accessed through trainings, presentations, and on websites.
3	Hold Events that Celebrate the Progress of the County
Hold at least one event per year that celebrates the progress of the County stakeholders that have made changes to organizational practice, expanded awareness to more and more community members, as well as policy change taken at the district, city, and county levels to institutionalize trauma informed and resilience practices as priorities.
4	Evaluate Progress
Each strategy of the Strategic Plan which is undertaken should include the development of an evaluation plan which can assist in determining the success of the strategy and opportunities for improvement. For example, evaluation by Stage could include:

Promoting Understanding and Education:
o	The number of individuals who have been reached by the media campaign by each advertising outlet
o	The number and location of film screenings
o	The number of new members who join the NFAA webpage group.
Activate and Take Action:
o	The number of champions identified
o	The number of agencies who have committed to workforce training and number of staff trained
o	The number of sectors with Resilient work plans and progress on reaching change targets in those plans.
                                   Keep the Momentum:
o	Feedback received
o	Progress on developing an evaluation plan
5	Ensure Wellness of People Providing Trauma-Informed Services
Providing services to children and adults who have experienced trauma can be challenging for those who are providing support. Providers and people in support systems need to have support of their own to deal with the burden of both traumas they may have experienced in their lives, as well as the traumas they are hearing about. Burn-out for providers and support individuals is common and should be taken seriously by providing wellness activities and other outlets for dealing with ongoing stress.
NEXT STEPS
With ongoing Resilience film screening events, an ACEs and resilience campaigns, community outreach presentations, NFAA’s Resilience Plan is to adopt the strategies listed above, which reflect both community and best practices learned among existing ACEs initiatives nationwide, that can help to establish a firm foundation for NFAA. If an individual, agency or community business or member is interested in becoming involved or would like information about ACEs work, contact any of the following partners for more information:

ACKNOWLEDGEMENTS
We would like to acknowledge and thank all the participants for their ideas and contributions to this vision for NFAA. This strategic plan is the commitment to the next steps of crafting a response to Adverse Childhood Experiences. Thank you for your dedication to ensuring that children and families throughout Northeast Florida are healthy and thriving and remain that way

APPENDIX A: Partners in this plan

ACEs Connection
A career journalist focused on science writing, Jane Stevens read about The Adverse Childhood Experiences Study, co-authored by Robert Anda and Vincent Felitti, and decided to write a feature story on the study findings that made the content more accessible to non- academics. She created a website, ACEs Too High, to share the original story, link readers to resources, and to continue to write stories about how communities were applying the concepts of the ACEs study in order to change practices.

From there, Stevens started the website “ACEs Connection” as a way for individuals, organizations, and communities to learn and share their in-process efforts to create trauma- informed, resilient communities. As a result, ACEs Too High and ACEs Connection reflect a breadth and depth of creative approaches to resilience building, as well as many lessons learned- all of which continue to inspire new efforts to apply knowledge of ACEs, trauma- informed practice, and resilience building strategies throughout communities.

Addiction Education Foundation

The Addiction Education Foundation, referred to as AEF, is a Florida 501(3)c non-profit organization whose goal is to provide education, training, workshops, information and resources on substance abuse, addiction, prevention, and recovery. Our mission is to provide solutions that will address and meet the many needs of our community. 

AEF currently provides trauma informed care, training, and education to Project WARM and the Volusia County Drug Court- 

Project WARM is a residential behavioral healthcare program housed in what was earlier the Vince Carter Sanctuary. Named after the famous NBA all-star who help set it up, the facility was an upscale treatment center that got repurposed into a state-funded rehabilitation center. The treatment center is situated about 10 miles away from Daytona Beach in Bunnell, Florida.
Project WARM is an acronym for Women Assisting Recovery Mothers. As the name implies, the facility serves substance abuse victims who are pregnant women, postpartum or parenting young children. The residential track offered here ensures that children are provided with daycare support while their mothers undergo rehabilitation and therapy. 

The Drug Court Program currently operates in Flagler, Putnam, St. Johns, and Volusia counties. These programs serve non-violent offenders with documented histories of substance abuse. Court proceedings are conducted in Bunnell, Daytona Beach, DeLand, Palatka and St. Augustine. 
Through an extensive supervision and treatment regimen, Drug Court programs adjudicate cases in which offenders are chronic substance abusers. Drug Courts require offenders to acknowledge their substance abuse problems and provide them with the tools and mechanisms to deal with their addictions. All of this is done in an effort to reduce or eliminate future criminal conduct. The Drug Court program uses a team approach to serve its participants. Team members include the judge, prosecutor, defense attorney, treatment specialists, supervision officers, law enforcement agencies, corrections officials, and others. Once an offender successfully completes this intensive program, the Court may dismiss the charge, reduce the sentence, or offer a combination of other incentive.

Community Coalition Alliance

In Florida, the Department of Children and Families (DCF) Substance Abuse and Mental Health (SAMH) program office, allocates funding to sub-state Regions who manage contracts for behavioral health services at the regional level. Big Bend, Broward Behavioral Services, Central Florida Behavioral Health Network Inc, Central Florida Cares Health System, Lutheran Services Florida, South Florida Behavioral Health Network Inc. and South Florida Behavioral Health Network are the seven managing entities who work in partnership with the Florida Department of Children and Families in managing behavioral health care for people facing poverty who do not have health insurance.

State-funded behavioral health services help people and families who don’t have insurance gain access to much-needed mental health care services. Through this system-wide approach, people at risk for or diagnosed with mental health and/or substance abuse disorders who do not have the financial resources to seek care are able to find the help they need. Services provided through contracted behavioral health care providers include prevention, intervention, treatment, and care coordination to support optimal recovery.

The Community Coalition Alliance (CCA) is a state-funded coalition of coalitions that provides a forum for partnerships, community involvement and participation, and interagency cooperation and collaboration by focusing on the issues with data-driven decision-making and research informed strategies. Through ongoing support and funding, LSF Health Systems provides CCA the opportunity to contract with fifteen (15) community coalitions across the Northeast Region of Florida and four (4) community coalitions in the Southeast Region of Florida to implement community-based prevention strategies, provide technical assistance, and work to identify behavioral health priority areas through systematic data collection efforts.

The mission of CCA is to serve as a collective voice of community coalitions working towards the health and wellness of all Floridians. 
CCA’s vision of communities working together to provide Floridians a healthy, safe environment in which they can thrive.

To achieve our vision and mission CCA provides a forum for partnerships, community involvement and participation, and interagency cooperation and collaboration by focusing on the issues with data-driven decision-making, evidence-based strategies and the risk and protective factors. 

There are four key roles the agency incorporates including: 
 
•	Membership 
•	Funding & Oversight 
•	Training & Technical Assistance 
•	Partnership Engagement 

Prevention Coalition OF St. Johns County

Florida Department of Health in Duval County

CDC

APPENDIX B: Additional ACEs Science and Research Findings
The initial study which identified the link between ACEs and long-term health outcomes was conducted over 20 years ago. Since that time, there have been numerous studies which have produced similar outcomes and furthered the complex body of knowledge around ACEs, resilience, and trauma-informed care.

Dr. Nadine Burke Harris, Pediatrician and California’s first Surgeon General, ACEs expert, and author of The Deepest Well, explains the neurobiology behind the hormonal and immune systems’ negatively impact caused by toxic stress, resulting in illnesses such as those highlighted in the original ACEs study for adults: ischemic heart disease, emphysema, some forms of cancer, as well as other illnesses. In addition, Dr. Harris’ research found evidence that these health impacts are apparent and measurable in children, long before adulthood.
The health impacts of toxic stress on children can include development of asthma and impaired growth rate, as well as other conditions

In addition to the links research has identified between ACEs, toxic stress, and long-term health impacts, it has been identified that children inherit their parents’ genes that impact how they respond to stressors. The National Scientific Council on the Developing Child has identified that stress turns some genes “on” and others “off” at particular times and that researchers have been able to demonstrate that human newborns have similar stress response reactions as their parents-even without exposure to the same stressors.6 Simply put, the effects of ACEs can be passed genetically from generation to generation. This is known as epigenetics.

Together, the neurobiology and epigenetics begin to give a fully picture on the long-term health outcomes of ACEs.

Also, since the original study, research has identified two additional ACEs which have been linked to long-term health outcomes. These include
●	Often treated or judged unfairly due to race/ethnicity
●	Hard to get by on income somewhat or very often.

The Child and Adolescent Health Measurement Initiative (CAHMI) is dedicated to better understanding the prevalence of ACEs among children nationwide.7 Highlights from their most recent brief on ACEs include:
●	In 2016, 34 million children, nearly half of all U.S. children ages 0-17, experienced at least one ACE, and more than 20 percent experienced two or more ACEs.
●	Children were more likely to experience ACEs if they were residing in a low-income family and Black or Hispanic.
●	Children with even one ACE had more social and emotional challenges as well were more likely to be disengaged with school
●	Impacts of ACEs were reduced for children who had access to effective resilience strategies, especially access to healthy, positive relationships with caring adults.

6 Monk, C., Spicer, J., & Champagne, F. A. (2012). Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Development and psychopathology, 24(4), 1361-76.
7 Bethell, C, Davis, M, Gombojav, N, Stumbo, S, Powers, K. (2017). A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive. Johns Hopkins Bloomberg School of Public Health, October 2017. Retrieved from www.cahmi.org/projects/Adverse-childhood-experiences- ace

According to CAHMI, California ranks at 5th in the nation for having the lowest percentage of children with ACEs scores of 2 or more. In California, 16.4% of children experienced two or more ACEs, compared to 21.7% of children nationwide.

We do not yet have local data on the prevalence of ACEs for NFAA County, but we can look at how NFAA County children are faring on the health, learning, and well-being indicators which research has identified as being impacted by toxic stress. For example, according to the 2016-17 California County Scorecard developed by Children Now, in NFAA County:
•	Only 57% of 3rd graders are reading near or above grade level
•	Only 30% of 8th graders meet or exceed state standards in math
•	42% of 7th-graders are not at a healthy weight
•	15% of students were chronically absent from school. 8

As research has shown children with high ACE scores more likely to have learning problems and childhood illnesses, children who are struggling with learning, health, or connection to community could potentially be related to their ACEs scores. Building resilience in the community could therefore potentially have an impact on improving educational outcomes and increasing health and well-being for young people of all ages.

The good news is that much research has been done not only to illustrate that resilience reduces the harmful effects of toxic stress, but that effective, evidence-based strategies for increasing resilience have been identified. These strategies can be applied by individuals, organizations, and communities to improve the health, mental health, and behavioral outcomes for community members.

One of the largest reviews of research to identify evidence based, effective resilience strategies has been conducted in partnership between the University of California, San Francisco (UCSF), and the San Francisco based Center for Youth Wellness (CYW). In a review of over 16,000 academic journals on the functioning of healthy and unhealthy stress response systems, six areas of intervention that can help children reduce toxic stress have been identified. These areas include:
●	Strong supportive relationships
●	Mental health support
●	Good sleep hygiene/routines
●	Healthy nutrition
●	Regular exercise
●	Mindfulness practice

Each of these six areas is demonstrated in research to have a direct and significant impact on how the human body regulates stress hormones and other aspects of the neurobiology of toxic stress.

8 Children Now. 2016-17 County Scorecard. Retrieved from http://pub.childrennow.org/2016/

APPENDIX C: Outreach Presentation Feedback
Three questions to ask at each of the presentations focusing on the impact of ACEs and Resilience  and identifying important groups with whom we should share this message about ACEs and Resilience. Audience response to the questions expressed common themes drawn from the presentation material. 

1.	How have you seen ACEs and resilience impact your work?

2.	In thinking about ACEs and resilience, what should we consider as we begin to develop this strategic plan?
3.	Are there other groups with whom we should be sharing this message?
Participants shared a list of people we should be sharing the ACEs message with (next to each group shows how many times the group was mentioned by the participants).