|By the Health Care Innovations Exchange Team|
Please tell us about yourself and your work.
I am a psychiatrist by training. While I did not receive specialized training in child psychiatry, I have always considered myself a “community” psychiatrist—that is, I serve anyone in the community who needs help. In the early 1980s, I found myself caring for a lot of children, as there were few if any child psychiatrists on the southwest side of Chicago. Most of these children were failing in school and had behavioral problems. Talking with them, it became apparent that many had seen—and in some cases been victims of—violence at home and/or in their communities. I began writing about the link between violence and childhood mental health and behavioral issues at that time, including publishing data that demonstrated the link. However, not many people paid attention.
In 1987, I became chief executive officer (CEO) of the Community Mental Health Council, a comprehensive community mental health center serving south and southwest Chicago that provides psychiatric services to adults and children, including residential housing, psychiatric emergency services, psychotherapy, vocational rehabilitation, day treatment, and consultation and education services. The Council has 3 main offices for outpatient services, 10 residential facilities, and psychiatric emergency rooms located within 2 general hospitals.
Around the same time, I launched the Institute for the Prevention of Violence as part of the Community Mental Health Council. With a staff of roughly eight individuals, the Institute promotes the use of strategies to strengthen families and communities. The goal is to prevent and mitigate the effects of childhood violence and other forms of trauma. The Institute’s work accelerated after President Clinton came into office in 1992. The President had witnessed firsthand the problem of violence in the family, having seen his stepfather hit his mother1. He cared deeply about the issue, so much so that he supported violence prevention initiatives and legislation.2,3
I also serve as the Director of the Institute for Juvenile Research, a 100-year old organization that originally formed after community leaders noticed that children of recent European immigrants in Chicago tended to have high rates of delinquency, often because their parents spent most of their time working to make their way in a new, unfamiliar country. Rather than taking these children from their parents and/or jailing them, community leaders created Juvenile Court to support them, and also got the state of Illinois to fund an institute to learn more about how to do so. That institute is now known as the Institute for Juvenile Research.
How does childhood violence and trauma affect a person, in terms of both mental and physical health?
In the late 1990s, Drs. Vincent Felitti and Robert Anda conducted a study on the impact of a chemical on weight loss. They found that the chemical worked quite well, helping extremely obese individuals lose hundreds of pounds. However, a year later, they had gained most or all of the weight back. When the doctors investigated why, the subjects told them that no one ever inquired about or addressed the underlying factors driving the risky behaviors that led to their weight gain4. Discovering this connection, Dr. Felitti and Dr. Anda began the Adverse Childhood Experiences (ACE) study. This large-scale investigation, which focused primarily on insured, middle-class families of various racial and ethnic backgrounds, identified seven ACEs that can lead to both mental and physical health problems later in life. They include physical abuse, emotional abuse, sexual abuse, domestic violence, and drug use by an adult, incarceration of an adult, and mental health problems in an adult in the family. Overall, half of the subjects experienced at least one of these ACEs, with roughly 6 percent experiencing four or more. Those experiencing at least four ACEs faced a significantly higher risk of depression (4.6-fold increase in risk), suicide attempts (a 12-fold increase in risk), and drug use (10-fold increase in risk). Interestingly, these individuals also faced greater risk of physical health problems, including double the risk of cancer and heart disease, four times the risk of lung disease, and 2.5 times the risk of getting a sexually transmitted disease.5 These children tended to engage in risky behaviors that threatened their physical health, such as trading sex for affection and drinking and smoking. So the ACE study and subsequent studies over the last decade have established a clear link between childhood trauma and both mental and physical health problems.
So what can be done about these problems? What reduces the risk and mitigates the impact of childhood violence and trauma?
Not everyone who experiences multiple ACEs ends up having behavioral and physical health problems. For example, everyone who has lived through four ACEs does not attempt—let alone commit—suicide. In fact, 5,000 out of every 100,000 people attempt suicide in their lifetime6,7, but annually only 11 out of 100,000 commit suicide.8 So clearly something must be protecting those who attempt suicide but do not complete it. Recognizing this, researchers began investigating the concept of “protective factors” (i.e., factors that somehow protect those at risk from experiencing negative mental and physical health outcomes). In 2001, I worked on the Institute of Medicine (IOM) report entitled Reducing Suicide: A National Imperative (http://www.nap.edu/catalog.php?record_id=10398) and later on Youth Violence: A Report of the Surgeon General (http://www.ncbi.nlm.nih.gov/books/NBK44294/). These reports came to an important conclusion about risk factors—that is, that they are not “predictive” of negative outcomes due to the presence of “protective factors” that guard against them. Since these reports came out, our understanding of the concept of protective factors has expanded thanks to the findings of various studies and reports related to prevention, health promotion, and public health. (See the Suggested Reading list for references to some of these publications.) As a result, the notion that protective factors can reduce adverse outcomes has become widely accepted.
The key issue, therefore, is how to promote the presence of protective factors. Studies have shown that overall, 30 percent of children with conduct disorder turn out to be career criminals9. Something, therefore, protects the other 70 percent. Further investigation suggests that the key issue relates to the strength of the social fabric in the community. Children generally lack judgment because the reasoning parts of their brain (e.g., judgment, wisdom, the ability to discern) do not fully develop until around age 26. Consequently, they need support within the community to apply “brakes and steering wheels” (i.e., limits on their behaviors) that they do not have.
So how does one promote protective factors, including a strong social fabric in the community?
Promoting protective factors requires biological, psychological, and social interventions. The goal is to change behaviors, which is inherently more difficult than achieving a purely medical benefit. For example, giving a flu shot is much easier than getting health care providers to wash their hands before seeing patients. Nonetheless, some “low-hanging fruit” exists when it comes to promoting protective factors. Studies show that omega-3 fatty acids improve and strengthen the development of the frontal lobe portion of the brain, which controls reasoning and judgment. Hence, the consumption of omega-3 by children and adolescents can help them develop and strengthen these areas of the brain.10 To promote the consumption of foods rich in omega-3 and/or use of omega-3 supplements, health care providers can talk to their patients, and public health officials can consider policies that promote use of omega-3 fatty acids in foods, particularly those that children regularly consume.
To address the psychological and social aspects of the equation, the focus should be on strengthening families so that children have a sense of safety, self-esteem, and mastery in their families and communities. This idea is based on seven established field principles:11,12
- Rebuilding the village, or social fabric of the community.
- Ensuring access to both ancient and modern technologies, such as omega-3 fatty acids and strong parenting skills.
- Promoting connectedness, including good relationships among families and communities.
- Promoting social and emotional skills in parents and children, including controlling one’s emotions and resisting the temptation to resort to violence.
- Increasing self-esteem and the sense of power, as those with a sense of power generally do not resort to violence.
- Creating protective shields and strengthening protective factors for adults and children.
- Minimizing trauma by turning “learned helplessness” into “learned helpfulness.” Trauma itself often does not cause damage. Rather, damage occurs when someone feels helpless in the face of trauma. Giving those experiencing trauma the ability to take action makes them feel empowered and reduces the impact of the trauma.
Are there specific strategies that have been (or should be) disseminated in this area?
The Institute for the Prevention of Violence promotes dissemination of proven strategies for building protective factors and reducing the negative mental and physical health problems caused by childhood violence and trauma. These include the following:
- Psychological First Aid: Developed in the 1980s, Psychological First Aid involves training parents, physicians, nurses, pastors, school counselors, community aid workers, and others to recognize and respond to the signs of childhood exposure to violence, such as a child who refuses to talk or who engages in “clingy,” regressive behavior (e.g., crying, bedwetting). Training emphasizes how to respond to and support these children. The Institute has trained many individuals on this concept, including staff of the Illinois Department of Family Services.
- Family Talk: Developed by Dr. William Beardslee from Harvard, Family Talk seeks to strengthen families by teaching family members how to become more closely connected to each other. The approach has been used widely in the United States and Europe.
- ABAN AYA Youth Project: This project, conducted in 12 public schools in Chicago in the 1990s, sought to reduce violence, drug use, and sexual activity in children and adolescents by promoting protective factors through use of an Afro-centric social development curriculum delivered over a 4-year period, beginning in the fifth grade. The name is drawn from two Ghanaian words—aban (fence), which signifies social protection, and aya (the unfurling fern), which signifies self-determination. The program promotes abstinence from sex and teaches students how to avoid drugs and alcohol and resolve conflicts in a nonviolent manner. The program was highly successful in reducing violent and provoking behavior, school delinquency, and drug use among boys. It also reduced the likelihood that boys would engage in sexual intercourse and increased the use of condoms among those who did. (More information can be found at: http://www.socio.com/srch/summary/pasha/full/passt24.htm.)
What can health professionals do to promote protective factors and prevent and/or mitigate the effects of violence?
Health professionals can play a variety of roles. Historically, they have played the very important role of conducting the research necessary to understand the issues and specific strategies for addressing them. This work, however, has largely been completed. Physicians, nurses, and other staff can screen for potential problems when children come in for office visits. Our organization has worked with the American Academy of Pediatrics on “anticipatory guidance,” which calls for pediatricians to ask certain questions that help to anticipate problems. For example, when mothers bring a baby to their offices, pediatricians or their office staff often ask whether potential poisons might be within the child’s reach (e.g., under an unlocked sink). They also need to ask about issues that could create the potential for violence, such as not having someone available for babysitting on occasion (which can lead to parental frustration and stress). If parents do not have someone available, the family should be connected with sources of support. Pediatricians should also routinely screen for psychiatric disorders, including exposure to violence or other forms of trauma. Many pediatricians do not perform such screening because they feel incapable of treating whatever problems they may uncover.
For their part, large health care systems should begin investing in health promotion and prevention, including community-based staff focused on building the social fabric of the community and supporting parents, with the goal of boosting protective factors. The Patient Protection and Affordable Care Act includes multiple components designed to transform the health care delivery system away from tertiary care and toward health promotion and prevention. Many of these initiatives, including accountable care organizations and patient-centered medical homes, create incentives for large health systems and other organizations to promote protective factors in families and communities. 13
What are the implications for the healthcare workforce?
The transformation from a tertiary-focused to a prevention-focused system requires the reallocation of staff to focus on building the social fabric of communities. It need not mean more health care workers, just a shift in the kinds of activities being pursued. It likely means less staff delivering acute and tertiary care and more staff working in the community.
Much can be done without adding staff. The Internet and other technologies offer the potential to promote protective factors without direct human involvement. For example, Internet-based applications have been developed that help to identify and support those at risk of depression, primarily through education that teaches at-risk individuals to appreciate and strengthen their protective factors and hence cultivate resiliency. Similar programs have been developed for human immunodeficiency virus prevention. For example, an application aimed at gay men has been shown to cut risky sexual behaviors in half.
- Bell CC, Flay B, Paikoff R. Strategies for health behavioral change. In: Chunn J, editor. The health behavioral change imperative: theory, education, and practice in diverse populations. New York: Kluwer Academic/Plenum Publishers; 2002. p. 17-40. Available at: http://people.oregonstate.edu/~flayb/MY%20PUBLICATIONS/Multiple%20behaviors/Bell,Flay,Paikoff.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
- Dove HW, Anderson T, Bell CC. Mental health and its impact on the health in the U.S. nonwhite population. In: Satcher D and Pamies RJ. Multicultural medicine and health disparities. New York: McGraw-Hill; 2005. p. 295-303.
- National Research Council and Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press; 2009. Available at: http://www.iom.edu/CMS/12552/45572/64120.aspx.
- Bell CC, McBride DF. Family as the model for prevention of mental and physical health problems. In: Pequegnat W and Bell CC, editors. Family and HIV/AIDS: cultural and contextual issues in prevention and treatment. New York: Springer Publishing Company; 2011. p. 47-68.
- Bell CC. Seven basic principles of violence prevention. In: Collaborating for family and community violence prevention. National Conference Proceedings, October 1-3, 1995. Available at: http://www.eric.ed.gov/PDFS/ED409396.pdf.
- Bell CC. Cultivating resiliency in youth. J Adolesc Health 2001;29:375-381. [PubMed] Available at: http://www.giftfromwithin.org/pdf/carlbell.pdf.
- Bell CC, Jenkins EJ. Traumatic stress and children. J Health Care Poor Underserved. 1991 Summer;2(1):175-188. [PubMed] Available at: http://www.giftfromwithin.org/pdf/children.pdf.
1Kelley, Virginia. Leading with my heart, my life. Simon & Schuster. 1994; 288 pages.
2Maraniss, O. First in His Class: A biography of Bill Clinton. Simon & Schuster. 2008; 512 pages.
3Drake, A. Bill Clinton: Why he’s a champion for family violence prevention. Accessed online at http://annecarolinedrake.com/2009/07/23/bill-clinton-why-hes-a-champion-for-family-violence-prevention/.
4Felliti, V, Jakstis, K, Pepper, V. et. Al. Obesity: Problem, solution or both? The Premanante Journal. 2010; 14(1): 24–30
5Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Child Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults—The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258. [PubMed]
6Joe, S., Baser, R., Breeden, G., et. al. Prevalence of and risk factors for lifetime suicide attempts among blacks in the United States. JAMA. 2006; 296(17): 2112-2123.
7Bell, C., Clark, DC. Violence among children and adolescents. Pediatric Clinics of North America. 1998; 45(2).
8Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars.
9Chandler, J. Oppositional Defiant Disorder (ODD) and Conduct disorder (CD) in children and adolescent: Diagnosis and treatment. Accessed online 2-24-2012 at http://jamesdauntchandler.tripod.com/ODD_CD/oddcdpamphlet.htm#_Toc179711707
10Gómez-Pinilla et al. Brain foods: the effects of nutrients on brain function. Nature Reviews Neuroscience, 2008; 9 (7): 568 DOI: 10.1038/nrn2421
11Bell C, Merritt L, Wells S. Integrating cultural competency and evidence-based practice in child welfare services: A model based on community psychiatry field principles of health. Children and Youth Services Review. 2009; 31(11): 1206 – 1213.
12Bell C, Bhana A, Petersen I, et al. Building protective factors to offset sexually risky behaviors among black south african youth: a randomized control trial. Journal of the National Medical Association, 2008; 100(8): 936 - 944. At http://www.medicine.uic.edu/cms/One.aspx?portalId=443021&pageId=1279683
13Affordable Care Act: Laying the Foundation for Prevention. HealthReform.gov accessed online 2-24-2012 at http://www.healthreform.gov/newsroom/acaprevention.html
About the author:
Carl C. Bell, MD, FAPA, FACP, is President and CEO of the Community Mental Health Council, founder and CEO of the Institute for the Prevention of Violence, Acting Director of the Institute for Juvenile Research, and a Professor in the Department of Psychiatry and the School of Public Health at the University of Illinois at Chicago. He has developed, tested, and promoted the dissemination of innovative strategies to prevent and mitigate the impact of childhood violence and trauma for more than 30 years.
Disclosure Statement: Dr. Bell is aware of the Innovations Exchange requirement to disclose any financial interests, or business or professional affiliations, relevant to the work described in this commentary. He disclosed no conflicts of interest.