When Child and Adolescent Psychiatrist Adrienne Coopey
first arrived at Mission Health in
Asheville, North Carolina, six years ago, the amount of
trauma she was seeing in patients coming in from across
the region was "mind-blowing."
"It was more than I had anticipated; it was
intense. I don't think I realized how much child abuse
there was in western North Carolina." Around
that time, Coopey attended a presentation about adverse
childhood experiences, otherwise known as
"ACEs." She wasn't the only mental
healthcare professional in the group who hadn't heard
about the damage ACEs can cause to not only the emotional
or mental health of a child but also their physical
health later in life.
Coopey recalls the reaction in the room:
"People were stunned. I was stunned. I said,
'We've got to do something!'" But the response
she got from her colleagues wasn't nearly as
enthusiastic, "because talking about child
abuse is really hard," Coopey admitted.
What are Adverse Childhood Experiences?
childhood experiences are significant disturbances in
a child's life that affect their security and ability to
function in healthy ways. ACEs include all forms of child
abuse (emotional, physical, or sexual), neglect (physical
or emotional), or household dysfunction (divorce,
violence, incarceration, substance abuse, or mental
The original 1998 CDC-Kaiser Permanente Adverse
Childhood Experiences (ACE) Study was the first to
examine the link between ACEs and physical and mental
health outcomes. Findings showed that the more ACEs a
child experienced, the greater the risk of chronic health
conditions, anxiety disorders, low life potential, and
even early death.
Subsequent studies have backed the original ACE research
and have found that, because the central nervous system
closely interacts with the body's immune, hormone, and
clotting systems, adverse experiences in a child's life,
especially repeated ones, can
change how the organ systems function later on. This
process is known as "biological
embedding" and could take years or even decades
before symptoms start to show.
ACEs in Rural America
A 2015 HRSA report (no longer available online) found
that rural children are more likely than urban children
to experience certain kinds of adversity. This and other
research prompted the Maine Rural Health Research Center
to go a step further to find out how ACEs have affected
rural and urban adults. Dr. Jean Talbot was lead
researcher for the Center's
Adverse Childhood Experiences in Rural and Urban
Contexts study that was released in 2016.
Using the most recent available data from the Behavioral Risk
Factor Surveillance System Assessment (BRFSS), Talbot
and her team found that, while the prevalence of ACEs was
comparable in rural and urban adults, over half of rural
adults surveyed reported having ACE exposure. Among those
with any ACE history, about one quarter experienced four
or more ACEs.
The significance? "ACEs cluster together.
People who report having an ACE are more likely to have
more than one," explained Talbot.
"It's easy to think of ways that this could
happen. For example, if a parent experiences
incarceration or mental illness, this in itself is an ACE
for the children in the family, but it can also impair
the adult's ability to care for kids. So it may open up
the fault line exposing children to other types of
Talbot notes that their study's results have implications
on the health status of rural America: "We know
that ACEs are linked to high-risk health behaviors like
smoking and alcohol abuse. These, in turn, contribute to
health outcomes like heart disease, lung cancer, and
diabetes – some of the major causes of the widening
rural-urban mortality gap. So, if we want to close this
gap, we may need to address rural ACEs as part of that
The ACE Learning Collaborative
Around the time ACEs were introduced to Coopey, the ACE
Learning Collaborative for Buncombe County was formed.
Born out of a state-funded innovative approaches grant,
it serves as a launching pad for the North Carolina
county's many efforts to address ACEs.
Coopey is now a co-coordinator of the Collaborative. She
views it as a support group of sorts for professionals
who are working continually to address ACEs.
"It's hard to do child psychiatry and trauma
work all the time, so knowing that there is a bigger
picture and that we are really having a greater effect on
the community makes my day-to-day much more
rewarding," she said.
The group is now made up of multiple primary care and
mental healthcare agencies, community groups, and
individuals who have helped Buncombe County become a
trauma-informed community of practice. Institutions like
the county jail and local law enforcement partner with
Family Justice Center – an intervention service for
intimate partner violence, of which Buncombe County ranks
one of the top counties in the state. Mountain Area Health Education
Center (MAHEC) puts on a biennial ACE summit that
attracts people from all over the nation. Buncombe County
School District efforts, led by Director of Student
Services David Thompson, are working at the ground
level with students trying to stop the negative
repercussions before they set in.
Compassionate Schools of Buncombe County
When he joined the ACE Learning Collaborative, Thompson
trauma-informed care was what schools in his district
really needed in order to address ACEs. With Buncombe
County's wide socioeconomic spread, Thompson witnessed
adverse childhood experiences on every level.
Buncombe County is part of the Appalachian region,
covering a large geographical and cultural range. Within
the school district, there are 71 languages spoken and
600 homeless students. Fifty-four percent of students are
eligible for free or reduced lunches. Prior to 2014,
there were not enough school counselors to go around,
especially for the rural schools in his district.
"When you have a small school with a high need,
you've got to be able to have a comprehensive supportive
program. You can't say to a student, 'You can't see the
counselor until they are back next Wednesday' when next
Wednesday, they might need something else,"
Thompson and his colleagues received the
Elementary and Secondary School Counseling grant to
hire more school counselors, fund trauma-informed
strategies, and improve care coordination in Buncombe
County schools. Out of the funds, they launched
Compassionate Schools: The Heart of Learning and
Teaching, a program that engages ten key principles to
help students learn self-regulation, resiliency,
executive functioning, and social/emotional competencies.
Prior to the start of the program, trauma was usually
addressed only after it triggered an emergency room
visit. Now, school's staff are trained to recognize signs
of trauma in students and respond appropriately through
their coordinated care system.
Because trauma is sometimes outside of a parent's or
educator's ability to intervene, giving a child tools to
change their thought or behavioral patterns when
encountering trauma is a way to build resiliency, which
Coopey defines as the ability to "bring
yourself back to a baseline that helps you interact with
the world around you." Thompson's work to
implement resiliency principles is evident throughout the
school and its students.
Each school has the option of integrating additional
models like the Community
Resiliency Model or
Mindful Schools that teach quick methods to engage
both mind and body. Classrooms set up "calm
spots" that students can visit to
"reset their brains." Teachers or
students lead exercises like "rocket
breathing" to regulate functioning. Students at
Fairview Elementary demonstrate in this video:
The science behind each activity's effect on the brain is
taught to students in every grade. "We now have
kindergarteners that can tell you about their
amygdala," reported Thompson, who takes pride
in how even the smallest of students are using the
Compassionate Schools tools.
Coopey has witnessed the effect Compassionate Schools has
on area youth and applauds Thompson's team.
"The Compassionate Schools program couldn't be
neater," she said. "It's something
that will really affect a large population of people
because it not only affects their children but also their
This video created by FrameWorks Institute, a nonprofit
that specializes in social science analysis, explains
how building resiliency can help people cope with ACEs.
Fostering Futures in Menominee Nation
Nearly one thousand miles away from Buncombe County is
Menominee Nation, an American Indian tribe in Wisconsin
with similar economic hardships. "If you choose
to work or live in this community, you have to know its
history," said Diane Hietpas. A non-Native, she
moved to the reservation as a dental hygienist and has
familiarized herself with some of the tribe's significant
historical events that are still impacting today's
Starting in the 1860s, Menominee children were removed
from their homes and forced to attend boarding schools
away from their tribe to learn Western culture. The
boarding school environment often included abuse and
neglect and, for many children, it was devoid of any love
One of the most recent traumatic events was the loss of
federal recognition as a tribe in the 1950s, resulting in
the depletion of jobs, closure of the tribal hospital,
and a host of other problems. Both events were
contributors to the intergenerational trauma that is
still prevalent in Menominee Nation.
"Our people struggled during this period. Some
of us were able to make it through with family support,
and others had a hard time adjusting," said
Jerry Waukau, administrator of the Menominee Tribal Clinic.
After being reinstated as a tribe in 1973, the clinic and
tribal leaders began looking at how to address some of
the ramifications. "What we were finding is
that a lot of people…were masking the pain: they were
self-medicating, and they didn't like to talk about
it," said Waukau. Substance abuse relapse and
criminal recidivism rates were high and
Menominee County outranked other Wisconsin counties
in the number of child abuse and neglect cases.
We had been talking about historical trauma for ten years
and the impact of poverty in our community. When we heard
the message about trauma and the science of ACEs, it just
In 2011, the tribe was chosen to be a pilot site for
Fostering Futures, a state-wide program that addresses
ACEs and toxic stress using trauma-informed care,
building resiliency, and reinstating hope in children.
The Menominee Tribe asked Diane Hietpas, who was trained
and experienced in conducting Screening, Brief
Intervention, and Referral to Treatment (SBIRT) for
alcohol and other drug abuse, to help manage the new
program from the Menominee Tribal Clinic. Hietpas worked
as a provider for years in the clinic and had developed
relationships with many of the families and patients. The
SBIRT screenings grew to include depression and domestic
violence; trauma screening seemed like a logical next
step. "We had been talking about historical
trauma for ten years and the impact of poverty in our
community," said Hietpas. "When we
heard the message about trauma and the science of ACEs,
it just made sense."
The clinic started with educating parents: encouraging
kindness, love, and positive tactics that add to a
child's resiliency. Their next focus was the Menominee Indian School
District, making resiliency a part of the everyday
education system in hopes of stopping the cycle of
intergenerational trauma. Then, they moved to the
community, holding trainings to build trauma-informed
care awareness at all levels in the tribe.
Much like Buncombe County's ACE Learning Collaborative,
champions for Fostering Futures represent an array of
organizations that work alongside the Menominee Tribal
Clinic. Agencies that were once hesitant to get involved
with helping youth have become some of the most engaged.
"It's finally happened and we are expanding our
partnerships within the community. We are now on a
journey to improve the health of our community that will
include cross-sector collaboration with a
patient-centered care approach," said Waukau.
Treating ACEs: "The Doctor Will Question You
While mental health practitioners are essential in the
effort to treat ACEs, it's the primary care providers who
often are the first responders to ACEs in rural
Essentials for Childhood Framework states that
providers conducting well-child visits can capitalize on
the opportunity to do something about them by talking
with parents about the importance of healthy family
relationships and practices.
ACE screenings also help determine a patient's ACE score,
which can identify an increased risk of behavioral and
physical health problems. Coopey is part of an ACE
Learning Collaborative workgroup that educates primary
care and mental health providers on the benefits of using
ACE questionnaire in their practices. The group has
been pleasantly surprised by the number of medical
providers who have agreed to give ACE screenings, but
still receive some pushback. "It's hard because
I think physicians are doers and they want a solution,
but with ACEs, there's not necessarily one
answer," explained Coopey. Although the ACE
questionnaire gives a score based on the answers, there
aren't set guidelines on how to treat patients based on
Coopey advises providers to start with compassion,
because a patient's noncompliance could be the result of
a multitude of reasons the patient can't even put into
words. "Understand that a person often isn't
trying to be defiant or doesn't care about taking their
medicine," said Coopey. "People's
adverse experiences affect how they interact with medical
care – their ability or desire to take their medications
and do what they need to do to care for
Coopey also suggests that providers can learn from
MAHEC's obstetrics program that uses motivational
interviewing during prenatal visits to discuss how
parental ACE scores could affect childrearing.
"To be able to present it to someone in a
non-judgmental way can be difficult, so this is a good
way to do it."
You can't just give a stranger this ACE test and expect
that everything's going to be fine. There has to be a
good, trusting relationship there. People need to be
ready to talk about it because it's very personal.
The Menominee Tribal Clinic will soon start ACE
screenings and resiliency questionnaires for WIC families
and obstetrics patients. Hietpas is training staff on how
to preface ACE questionnaires with an explanation. She
added, "You can't just give a stranger this ACE
test and expect that everything's going to be fine. There
has to be a good, trusting relationship there. People
need to be ready to talk about it because it's very
This is where rural providers have an advantage
— because of their close-knit environments,
many rural clinicians have already built those trusting
relationships, making it easier to ask personal questions
and receive an honest response.
Hope for Menominee and Buncombe County Youth
Hietpas and Waukau recognize that, with the amount of
trauma and transgenerational trauma, progress to reach
their goal of "no child in Menominee County
ever having an ACE again" most likely won't be
in their lifetime. But there is hope. "If we
don't create hope for those kids, it becomes a hopeless
situation, and then what? They're another statistic and
they'll continue the same cycle their parents were
in," said Waukau.
In the past, Menominee Nation has rallied behind efforts
to reduce alcohol abuse and other harmful behaviors. With
this new focus on ACEs and trauma-informed care, they are
hoping for the same spirit. "Come back and talk
to us in five, ten years, but for right now, we'll take
those little wins – one family at a time. That's how we
are going to build this change process," stated
The question 'What is wrong with this child?' is being
replaced with 'What has happened to this child?'
Buncombe County School District has
learned many lessons through the implementation of
Compassionate Schools. There are pockets of evidence
proving their efforts are paying off.
"Principals are saying, 'This makes a
difference, more than anything we have ever
done,'" relays Thompson. He has also seen a
shift in the way teachers look at their students. The
question "What is wrong with this
child?" is being replaced with "What
has happened to this child?"
As with any new initiative, there is still work to be
done, but Thompson is encouraged by the potential this
model has to launch healthy students into the world.
"We want our students to be both college,
career, and community-ready," he
stated. "You are not going to ever be able to
avoid problems in life, but how you are able to bounce
back and respond is the key."
When working with children affected by ACEs, Coopey tries
to identify with their needs, remembering that their
experiences carry on into adulthood and, ultimately, form
our future societies. Coopey reminds educators, medical
providers, psychiatrists, and advocates of mental health
of their significant role in a child's life:
"There are plenty of people who have a high
number of ACEs and are doing alright," she
said. "Often, they had that one safe, stable,
nurturing adult who was able to give them skills to cope
in their situation and to support them."