Let's Face Adverse Childhood Experiences

Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 1 of 20

RESEARCH ARTICLE Let’s Face Adverse Childhood Experiences (FACE) It: Parent Education and Empowerment

Chia Thao1,*, Irán Barrera2, Uyen (Sophie) Nguyen2

Authors’ affiliations: 1 California State University, Fresno, USA 2 Fresno State Department of Social Work, USA

*Corresponding author: Chia Thao California State University, Fresno, USA Email: [email protected]

ABSTRACT

Adverse childhood experiences (ACEs) are a major public health concern in the United States as childhood trauma can lead to long-term health and mental health consequences. They disproportionally affect low-income children of diverse backgrounds; however, parent education can potentially reduce ACEs among low-income young children. This study aims to examine whether parents’ perceptions toward ACEs changed after exposure to ACEs- related infographic education. In this study, we identified three main themes across the focus group interviews that highlight the importance of ACEs-related educational intervention. Following the ACEs-related education, our study found that the vast majority of participants’ attitudes toward and perceptions of ACEs changed from normalizing ACEs to acknowledging and accepting the consequences of ACEs; the participants also reported feeling empowered to prevent the cycle of ACEs. More importantly, the participants recognized that ACEs could cause long-term traumatic damage to the exposed child’s health outcomes, and they felt empowered to seek resources for ACEs-related interventions. These findings shed positive light on the significance of educating parents on ACEs, which should be considered for policy implications and program interventions to prevent child maltreatment in the United States. We propose an intervention model using the health literacy and educational empowerment frameworks along with other policy recommendations that highlight the importance of culturally and linguistically appropriate services for diverse families living in low-income housing communities.

Keywords: educational intervention; empowerment; Latino; African American; Hmong; low-income housing; Fresno

1. INTRODUCTION (Putnam, 2006). Some parenting education programs have shown success in reducing Adverse childhood experiences (ACEs) are child abuse. One of the most evidential a major public health problem in the United findings is from the Supporting Kids And States, as short-term and long-term Their Environment (SKATE) program in childhood trauma can have a detrimental Australia, which was a child-focused impact on one’s mental health (Dube et al., intervention designed by an 2001; Edwards, Holden, Felitti, & Anda, interdisciplinary team to address ACEs. The 2003; Felitti et al., 1998; Jonson-Reid, study found that educational intervention Drake, & Kohl, 2009; Burke et al., 2011). improves family relationships, thereby The consensus of the body of literature improving children’s behaviors (Lewis, highlights that children who experience Holmes, Watkins, & Mathers, 2014). maltreatment such as physical, emotional, Similar studies have echoed the importance and/or sexual abuse are more likely to have of educational intervention and increased risks for several mental health implementation as ways to prevent ACEs problems, including substance use disorder, (Bethell, Newacheck, Hawes, & Halfon, depression, suicide attempts, and risky 2014; Bitsko, 2016; Lindert et al., 2014; sexual behavior (Hunt, Slack, & Berger, Putnam, 2006). However, existing literature 2017; Liming & Grube, 2018; Navalta, lacks clarity on the intervention of ACEs- McGee, & Underwood, 2018). For instance, related educational interventions among Hunt et al. (2017) suggested that children low-income disadvantaged communities. exposed to ACEs are at a higher risk of suffering from health issues and behavioral As a result, the goal of the current problems later in life. In addition, children study was to assess the impact of a 15- from disadvantaged communities, including minute ACEs education to residents of African-American children, children from diverse racial/ethnic backgrounds living in lower-income families, and children from low-income housing communities in the single-parent households, are more likely to San Joaquin Valley of California. The study experience ACEs at an early age than their aimed to identify changes in parents’ wealthy peers (Hunt et al., 2017; Liming & perceptions and attitudes about ACEs after Grube, 2018). Most importantly, ACEs can the educational intervention. This paper influence children’s behavioral and reports on the focus group conversations on academic outcomes (Jimenez et al., 2016; ACEs that followed the educational Keiley et al., 2001; Trzesniewski et al., intervention. 2006), leading to delinquency in adulthood (Bitsko, 2016; Kerker et al., 2015; Shin, 1.1 Prevalence of ACEs in the Central McDonald, & Conley, 2018). Valley, California

However, not all hope is lost. According to the U.S. Department Studies have shown that early prevention of Health and Human Services (2018), an and recognition of ACEs is critical for estimated of 3.5 million children were the preventing depressive disorders later in life subject of a child protective services

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 3 of 20 investigation in 2016, a 10% increase from (Anda, Butchart, Felitti, & Brown, 2010). 2012. Among those children, 17% were Social economic status is strongly investigations for child maltreatment (U.S. associated with poor parental mental health Department of Health and Human Services, and parenting behaviors (Conger et al., 2018). Similarly, child maltreatment was 1992, 1993; Linver, Brooks-Gunn, & reported in California (Webster et al., Kohen, 2002). 2018). Among such investigations, 223.2 invovled Native Americans, 166.3 African The Fresno community is diverse in Americans, 51 Latinos, 44 Whites, and 13.9 terms of racial and ethnic backgrounds. Asians (Webster et al., 2018). Income disparities also exist among minority communities in Fresno (Aratani, The Lucile Packard Foundation for Barrera, & Kelley 2017). According to the Children’s Health (2019) reported a higher U.S. Census Bureau (2015), 45% of Latino rate of child maltreatment in Fresno children and 44% of children with at least County. Among such allegations, 71.9 per one foreign-born parent live in poverty; 1,000 children under 18 years of age were meanwhile, it 41% for African Americans classified as cases of child abuse and and 50% for Hmong. Only 19% of White neglect—a much higher rate than children live in poverty (U.S. Census California’s state average of 54.6 per 1,000. Bureau, 2015). Such statistics are consistent According to the 2016 U.S. Census, Fresno with previous findings that children from County’s population was approximately diverse backgrounds are more likely to live 980,000;53% were Hispanic/Latino, 30% in poverty than White children in the White, 11% Asian, 6% African American, United States (Jiang et al., 2014). A higher and 3% mixed races. The largest city in the prevalence of child maltreatment has also county is Fresno, with an estimated been among racial/ethnic minority groups. population of 522,000. For instance, the Lucile Packard Foundation for Children’s Health (2019) used data from Fresno was known to have one of the California Child Welfare Indicators the highest concentrations of poverty in the Project to identify 185 cases of child abuse nation (Jiang, Ekono, & Skinner, 2014; and neglect per 1,000 children among U.S. Census Bureau, 2015), with 87% of African-American/Black children, followed the population living in a neighborhood by 71 among Latino children, 55 among identified as falling below the federal White children, and 32 among poverty guideline (Kneebone & Holmes, Asian/Pacific-Islander children. 2016). As a result, nearly 39% of children in Fresno live in poverty, compared to 23% The high prevalence of child in the state of California and 21% maltreatment among the racially diverse nationwide (Jiang et al., 2014; U.S. Census Fresno County community warrants a Bureau, 2015). Studies have shown that thorough investigation to better understand children living in poverty are more likely to the complexities of this issue in the Central experience frequent and intense childhood Valley. An interdisciplinary approach using adversities that can lead to early death the Health Literacy Model may be a

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 4 of 20 potential solution to address the empowerment for impoverished and overwhelming concern about child illiterate individuals (Freire, 2005; maltreatment in Fresno County. Nutbeam, 2000; Wallerstein, 2006) and serve as an asset for improving people’s 1.2 Health Literacy Model to Address empowerment through ACEs-related Child Maltreatment knowledge (Sørensen et al., 2012). Empowerment improves individuals’ Health literacy is defined as knowledge that actions and health outcomes (Wallerstein is: & Bernstein, 1988; Wallerstein & Sanchez- linked to literacy and entails people’s Merki, 1994; Crondahl & Eklund Karlsson, knowledge, motivation and competences 2016). As such, the purpose of this paper is to access, understand, appraise, and to examine how an ACEs-focused apply health information in order to educational intervention affects the make judgments and take decisions in perceptions of and attitudes toward child everyday life concerning healthcare, maltreatment among families of culturally disease prevention and health promotion diverse backgrounds living in low-income to maintain or improve quality of life housing communities in Fresno. during the life course. (Sørensen et al., 1.3 Empowerment Education 2012, p. 3). Component of the Intervention Model Studies have shown that limited literacy is Like health literacy, empowerment prevalent among those of lower education is an equally important element socioeconomic status and literacy of the ACEs intervention used in this study (Nutbeam, 2008; Porr, Drummond, & and merits distinction from its conjoined Richter, 2006; Sørensen et al., 2012). twin. Rappaport (1987, p. 121) defined Utilizing the health literacy model to empowerment as a process by which people address child maltreatment through efforts gain control over their life circumstances. such as ACEs-related education can Hence, empowerment education seeks to improve the current limitation and cultivate the power in others through an prevalence of ACEs among low-income, interactive process of sharing knowledge, low-literacy communities. expertise, and resources (Funnell et al., Healthcare professionals play a 1991). Brazilian educator Paulo Freire crucial role in encouraging the (1973) developed a theoretical framework effectiveness of ACEs-related education for empowerment education that asks the (i.e., education about child maltreatment). population-to-be-educated to identify their ACEs-related education is a powerful tool own issues and underlying causes as the for individuals—both victims and first steps and then set goals and formulate perpetrators—to comprehend the strategies to overcome their challenges and importance of poor ACE implications. The attain these goals. In this way, Freire’s health literacy model can foster empowerment education process enables others to develop new beliefs in their ability

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 5 of 20 to impact their personal and social spheres literacy promotion, as the effects of the two (Bergsma, 2004). Not only do empowered are intertwined. A high level of individuals have resource mobilization empowerment without a corresponding skills and perceived control over their own level of health literacy can lead to lives (Perkins & Zimmerman, 1995), but potentially harmful health choices by they also can affect group and systemic patients, whereas a low level of changes (Bergsma, 2004). empowerment coupled with high health literacy can prompt patients to develop In the realm of health, excessive dependence on health empowerment education engenders a professionals (Schulz & Nakamoto, 2013). psychological shift in patients, thereby changing the relationship dynamics The ACEs-related educational between patients and health professionals. intervention of this study was built upon Empowerment-oriented interventions focus both components. By showing parents the on understanding socio-environmental ACEs infographic, the research team aimed causes of health conditions, instead of to increase parents’ health literacy related to victimizing patients, and on providing ACEs, thereby giving parents some sense of opportunities for patients to build the control and empowerment to address the knowledge and skills necessary to improve issues. their well-being (Bergsma, 2004; Wallerstein, 2002). An empowerment 2. METHODS orientation identifies patients’ assets and The researchers used a vignette community capacity to foster protective approach to examine the perceptions of factors, going beyond the commonly used child maltreatment, as Lapatin and “powerlessness” discourse centered around colleagues (2012) found that “vignettes risk factors in patients’ lives (Wallerstein, provide a valuable approach that is 2002). The patients are no longer recipients acceptable to participants, elicits important of services; rather, they become active insight on participant experience and participants in their care, with health services” (p. 1345). As noted in the original professionals serving more as collaborators study (Barrera, Kelley, & Aratani, 2019), than as authoritative experts (Funnell et al., we believe utilizing a vignette style model 1991). to examine child maltreatment is an Therefore, empowerment education, appropriate approach for people of color. together with health literacy promotion, has As a result, three types of child been widely regarded as an effective health maltreatment scenarios were presented to education and prevention model and the participants to explore how parents evaluated in different types of programs perceived each scenario. We used (Funnell et al., 1991; Wallerstein, 2002; convenience sampling of families of diverse Wallerstein & Bernstein, 1988). A backgrounds who receive federal housing meaningful intervention would integrate subsidies from a local housing authority in both empowerment education and health Fresno, California. Because we focused on

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 6 of 20 developing prevention services utilizing brief 15-miute educational intervention mental health literacy and empowerment about the implications of ACEs. In this that are culturally sensitive, we first needed study, we focused only on the post results to know the beliefs or attitudes of the as the results for the pre intervention were groups in this study (i.e., Latino, Hmong, published already (Barrera et al., 2019). and African American). The advantages of conducting focus group interviews over individual interviews Our research question was: How do include the ability to promote more parents’ education about ACEs influence discussions on a difficult topic such as child low-income housing residents’ attitudes? maltreatment. In addition, in consultation with the housing staff, it was decided that 2.1 Data Collection and Analysis gathering participants would be easier via The researchers recruited a total of focus groups than individual interviews 24 participants for five focus group because of their unpredictable work interviews. Three focus groups were schedules. Finally, although we recognized conducted in Spanish, one was in English, the sensitive nature of the research topic, and one was in Hmong. Eligibility criteria we prioritized the feasibility and to participate in the focus groups were (1) completion of this study, so we encouraged having children and (2) receiving federal all members to actively participate. housing subsidies. Nine participants were Focus groups were held in July, recruited through parenting groups at August, and September 2017 at community locations managed by a local housing centers that are part of subsidized housing authority, which were in the city of Fresno complexes managed by the local housing as well as outside the city. The remaining authority. In general, focus groups should 15 were recruited through convenience occur in non-threatening environments with snowball sampling, where residents invited a group of individuals who share certain other residents to participate in the focus characteristics to allow for a good group group. Ultimately, participants included six dynamic and greater self-disclosure African Americans, seven Hispanics (Krueger & Casey, 2000). All five focus (including four participants who self- group interviews were conducted at identified as Mexican and three as locations most geographically convenient Hispanic), eight Hmong, one White, and for the participants. Focus groups were two who did not specify their race or conducted in private rooms, where ethnicity. The majority of participants were participants sat around a table and were female (n=25, 88%), although three males able to see one another. The focus groups participated in the Hmong focus group were conducted in the language that the (12%). The purpose of the focus group participants preferred (English, Spanish, or interviews was to understand the diverse Hmong). [Institution blinded for review] perspectives of parents in low-income Institutional Review Board approved the housing regarding child maltreatment, focus group procedures. Focus group which were measured before and after a

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 7 of 20 discussions lasted an average of 60 minutes, coders independently analyzed the data to ranged from 30 to 90 minutes, and were identify subcategories, categories, recorded for transcription purposes subthemes, and themes using MAXQDA (Krueger & Casey, 2000). software. Codes were compared, and any discrepancies were discussed among coders Interviewers read vignettes that in detail and then finalized to increase the described the maltreatment of three reliability and validity of our study. children, Jose, Eve, and Justin (see Appendix A), and then followed with a list 3. RESULTS of semi-structured guiding questions The participants were probed for examples, “There’s no real definite answer for clarification, and/or details in their [ACEs]. I think that what doesn’t responses. The focus group questions break you is gonna make you centered on their perceptions about how the stronger.” –A Latino parent children in the vignettes are treated (see A total of 21 interviewees captured Appendix B). the three main themes of the post ACE- After the vignette discussion, the related education discussions. Among the interviewers implemented a 15-minute individuals who initially rationalized infographic information session about the punitive parenting practices as part of significance of ACEs-related implications growing up or had mixed views about (see Appendix C). The interviewers ACEs, 77% changed their perceptions after presented thorough information on ACEs, learning about the negative implications of followed by post-discussion questions ACEs through the infographic, related to ACEs (see Appendix D). The acknowledging ACEs as a potential questions were developed to assist problem. Table 1 highlights the breakdown participants in engaging in a dialogue about of individuals’ perceptions following the ACEs after the educational intervention, ACEs-related education. Of the three with the hopes of capturing rich data around individuals who still had views and did not potential changes in their personal attitudes change their perspective about ACEs, two toward and beliefs about child acknowledged that the infographic maltreatment. Interviews questions were education was helpful and true. Overall, the transcribed and translated into English. vast majority of the participants (71%) Member-checking was conducted during found the infographic to be informative and focus group discussions to confirm the useful; it confirmed the poor impacts that credibility of narrative accounts. In the participants had observed after addition, peer debriefing was conducted to experiencing ACEs firsthand. assess focus group discussions along with a careful review of focus group notes. Coding consistency between coders was obtained by engaging in prior practice coding. Three

Table 1: Parents’ Views Post ACEs-related Education

Percentage of Summary interviewees (n)

Seemed to have some changes in viewpoints 48% (10)

From only rationalizing physical punishment/neglect to 19% (4) acknowledging it as a problem

From mixed views (seeing that physical punishment/neglect is bad, but rationalizing it) to 29% (6) acknowledging the negative impact of ACEs

Did not change viewpoints 33% (7)

Acknowledged ACEs as a problem 19% (4)

Mixed views 14% (3)

Mentioned that infographics were true or helpful 71% (15)

Talked about self-empowerment 52% (11)

Expressed viewpoints either pre or post ACEs-related education 19% (4)

Acknowledged ACEs as a problem (pre or post) 10% (2)

Mixed views (pre) 5% (1)

Rationalized ACEs (pre) 5% (1)

Total number of interviewees who talked about this topic 100% (21)

Through an ethnographic analysis of post perceptions from normalizing or justifying focus group transcripts, we identified three punitive parenting practices as part of main themes across all focus group growing up (“it is not so bad”) to viewing interviews that characterize participants’ those practices as a problem and perceptions of child maltreatment after recognizing their negative consequences, exposure to the infographic education. It is (2) affirming the usefulness of the important to note that we used findings infographic information, and (3) feeling from the initial study to come up with these empowered to seek resources to overcome themes (Barrera et al., 2019): (1) changing ACEs-related consequences. Parents were

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 9 of 20 also asked to identify what types of even if they have a rough childhood, as you resources they needed to prevent child get older—because you’re gonna be maltreatment. dealing with different people, even in relationships—eventually, you should learn 3.1 Changing perceptions of ACEs how to work against that.” The third rationalization of ACEs was that bad “[ACEs education is] like an alert experiences would help children know what for people or so that they can also to avoid, and these children could grow up understand what we go through into strong and healthy adults. Six sometimes, […], that we insult each participants discussed this view before they other in the family and think that saw the ACEs infographic. In particular, maybe it doesn’t have any effect, but one recalled: “Well my mom and my dad, it’s—sometimes it’s even greater they used to discipline us, they used to get than we think.” –A Latino parent the belt […] or whatever, and I feel like I By comparing participants’ discussions turned out okay. I don’t smack my kids. I do before and after they learned about ACEs tell them to behave and calm down, but I’ve through an infographic, we found that most never smacked them, so I think I turned out participants’ perceptions of ACEs shifted okay.” Another participant stated that, “if toward acknowledging the negative impacts [Jose’s] father is already an alcoholic and of ACEs. Prior to seeing the ACEs display[s] bad behavior […], the boy might infographic, only five participants (24%) learn from those bad examples and will not stated that experiencing ACEs would have turn out to be like his father. He will have harmful effects on children; nearly three- kept all the bad memories in his heart and quarters of the participants (n=15; 71%) will learn that these bad parenting skills either rationalized ACEs or expressed are unhealthy and will avoid being like this mixed views toward ACEs. Four father in the future.” Although some participants talked about how parents who participants recognized that ACEs could beat children mean well and that beating or adversely influence a child’s well-being, hitting a child is a disciplinary method: including mental health, the majority “Kids, when they grow up, some are justified those experiences. naughtier and must be disciplined by However, after the participants were hitting.” In responding to Justin’s vignette introduced to the formal concept of ACEs scenario, one said that, “if she [Justin’s through an infographic and had a chance to mother] isn’t a drug addict, then her ask questions about ACEs research, we saw beatings may be disciplinary matters, which a notable shift in their perceptions of ACEs. means that her beatings are with good By asking participants all the same intentions and she will love [her children] questions about the vignettes after a 15- after she teach[es] them the lesson.” minute ACEs-related information session, Another participant suggested that enduring we were able to compare each participant’s a rough childhood could teach a child early views about ACEs and identify possible on how to “deal with” others: “I think that

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 10 of 20 changes. Overall, almost three-quarters of mental health challenge in the the participants (n=15; 71%) acknowledged United States.” –A Hmong parent negative consequences of ACEs, and approximately 5% (n=3) maintained mixed The vast majority of the participants views afterwards. No participants purely indicated that the ACEs-related education rationalized ACEs as some had done before was informative and useful, providing seeing the ACEs infographic. Of the five important validation for their own participants who started out by justifying perspective and/or experience of ACEs. ACEs, four began to discuss the negative After the brief 15-minute educational effects of ACEs after learning about the intervention, the post discussion revealed research findings (the remaining participant that 71% of the participants acknowledged did not express any views after the that child maltreatment affects people’s infographic). Similarly, among the 10 physical, social, and emotional well-being. participants who had mixed views, six no Many participants validated that, due to longer mentioned their justifications for their similar childhood experiences to those ACEs and instead talked about ACEs of Jose, Eve, and Justin in the vignettes, consequences. One shared that “[ACEs they are now suffering from the poor education] is very informative and it’s also implications of ACEs. As one participant in like an alert for people or so that they can an African-American focus group stated, also understand what we go through “From my experience, yes. I’ve known a lot sometimes, […], that we insult each other of people with ACEs, like a whole large in the family and think that maybe it doesn’t group.” Another participant from the same have any effect, but it’s—sometimes it’s cohort said, “I’m an adult. I have some even greater than we think.” The ACEs, and according to this study that I’ve comparison between each participant’s obtained—so, what I’m saying is that it views pre and post the ACEs education lines up pretty well. What I’m saying also is reveals that the majority of the participants that it’s not really fair to have an umbrella who rationalized or had mixed views about statement. However, I do agree that this has ACEs initially started to acknowledge a lot of truth to it.” The validation was detrimental outcomes of those experiences further supported by the Hmong for children. The following section participants, as the vast majority in this discusses participants’ thoughts about the group stated, “Okay, well that means that information session on ACEs during the all of us here are sick because we faced focus group. hardships in Laos (referring to their war- time experiences, struggles, and 3.2 Validating the importance of ACEs deprivation). Growing up, we did not have educational intervention enough luxury to eat, nor did we receive the emotional support from our parents.” One “I believe that the findings from Hmong parent shared that “the findings ACE are true. We are living proof were very impressive. The results validated that ACE exemplified our our thoughts and feelings. We now realize childhood experience and current

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 11 of 20 that not just us, but people (children) with concluded, “I feel educated.” Most similar physical and emotional issues have important of all, the education empowered the same health outcomes.” Ominously, a many participants to want to change the Latino parent agreed on the poor situation of ACEs in their own family and implications of exposure to ACEs during community, as indicated by one Latino childhood and poor health outcomes into parent’s statement: “You’re gonna have to adulthood: “I definitely do feel it’s the truth, take some steps to make changes. You can’t all that, it does affect, abuse, neglect, all just do what you’re doing because what that, very true. So, yes, I do believe it is the you’re doing is just evading us. Moreover, truth.” Based on these discussions, most that’s what I did the entire time. I mean, not participants express overwhelming support everyone’s like me, but I just felt like if kids for efforts to prevent ACEs because the got more education—I know things are implications of ACEs reflect their own changing a lot. I mean, the fact that you’re experiences and health. here—[...] Education is very important.” Another Latino parent said, “I turned it 3.3 Self-empowerment to prevent ACEs around, and now my kids are in college.” Furthermore, an African-American parent “So in order to get out of that, we stated, “you know, if they’re willing to say, have to want it. And then when we ‘I am not going to live what I lived when I want it, we gotta be consistent and was young,’ they will do something about it while we're actually…[change/prevent ACEs].” One still struggling with all the other Latinno parent underscored the importance stuff.” –A Latino parent of preventing ACEs: “I think they’re gonna A dose of education about the be in that statistic still…that same statistic adversities of ACEs goes a long way. Our is gonna carry over to their adult life, in discussions about ACEs after the some cases, not all….I think that’s gonna educational intervention session provided carry over into their adult life if it (ACEs evidence that education changes individual program intervention) can’t be addressed perceptions about ACEs; most importantly, and avoided.” Other parents stressed the education empowered many individuals in importance of ACEs-related education as our study to want to break the cycle of follows: ACEs and seek resources to prevent ACEs. It’s also, like you said, a little The data indicated that, after the disturbing that it’s—where we now educational session, participants have to try to prevent and help the acknowledged ACEs as a problem. During children that we’re raising and try to the post discussion, one parent stated, “It make sure that they don’t pick up any (ACEs) makes sense, yeah. It’s just of these adversities so that they can disturbing, that’s all.” This point was have a better outcome. Moreover, if supported by a Hmong parent: “I agree with they do, be okay with saying, “How the findings from ACEs.” The session was can I get the help that you need or get also informative for a Latino parent, who

the services to make sure that you parents also expressed the challenge of the know you're okay with whatever limited existing programs. One parent you’re going through or how you explained: tackle some of these issues that you feel about yourself?” So, I like that What if you need behavioral health? you guys have the program, I like that What if you need mental health? A you guys are doing the research, lot of the times, it’s six months to a because without it, there would be no year out. A lot of the times, by the services. I do like the fact that you are time you get an appointment, the doing research on other ethnicities service is no longer available because it’s not just a black or white because it’s got chopped in funding. or Asian thing. It is about the children So, beware of the false promises. and about adults. Yes, this is okay for people who can pay for the service, but now, we’re Many individuals were motivated to seek a targeted group where we don’t services after being informed about the have a lot of money and we don’t unfortunate implications of ACEs. One have a lot of resources, and I don’t Latino parent asked, “How can I get the want my child being labeled a help that you need or get the services to statistics. make sure that you know you’re okay with whatever you’re going through or how you In short, we learned through the post tackle some of these issues that you feel discussion that the parents’ behavior and about yourself?” Another parent from the attitudes about the punitive impacts of same group said, “Now I have a child, so ACEs have severe consequences. After the let me make sure that doesn’t happen to educational intervention, parents felt her….I don't want that same thing to empowered to make a more informed happen to her.” decision about ACEs. Many emphasized the importance of seeking services for ACEs Self-empowerment was best intervention. On the other hand, there are summarized by a Latino parent: “You’re barriers for some parents seeking ACEs- showing up. That’s the first step. However, related services, as one parent reported the you gotta take it another step further lack of resources. Therefore, future studies yourself.” One Hmong parent clearly stated, should focus on the type of intervention “You need to go find these assistance services that can close the gap in services. programs. The government has already provided them, but you have to go find 4. CONCLUSIONS them. The correct way is for you to go find There are limited education them, not for them to find you.” It is intervention programs targeting low-income noteworthy that parents voiced concerns parents of racial minority groups in surrounding problems with current particular. Parent education and awareness programs due to the lack of resources for are a potential strategy for informing a ACEs intervention. About 30% of the

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 13 of 20 behavior change around childbearing and the experiences surrounding toxic stress, building nurturing parent–child especially in communities with limited relationships that can prevent ACEs or literacy surrounding trauma. This finding is buffer the negative consequences of ACEs significant as many low-income (Altafim & Linhares, 2016; Cowen, 2001; communities, including housing, do not McCarthy et al., 2002; Prinz, 2016). Our have access to information that could help study has shown that, after a brief ACEs- people make decisions about their own related education session, parents were well-being. For these reasons, we propose a more aware of the negative effects of ACEs three-step process utilizing health literacy on their children. As a result of being and empowerment to assist in alleviating informed about the adverse impact of issues surrounding ACEs for parents/family ACEs, parents’ knowledge of ACEs’ members (see Table 1). Utilizing Sørensen implications increased, and most parents et al.’s (2012) definition of health literacy became more accepting of the related presented earlier and Wallerstein and consequences. Parents felt empowered by Bernstein’s (1988) definition of the information and discussed ways to stop empowerment “as a social action process the cycle of ACEs in their own families and that promotes participation of people, communities. These findings shed a organizations, and communities in gaining positive light on the importance of control over their lives in their community educating parents on ACEs, which should and larger society” (p. 380), the first step is be considered for policy implications and to create culturally and linguistically program interventions to prevent child information on ACEs utilizing maltreatment in the United States. words/symbols and other meaningful knowledge geared for specific populations The results from our study add to (e.g., Latino, African American, and the small body of literature on the Hmong). Next, create culturally and importance of an ACEs intervention linguistically competent parenting programs program. Despite the limitations of the to promote healthy parenting practices. small sample size and no control group is Finally, refer parents/family members to present, our finding suggests some positive organizations addressing issues surrounding effects of educational interventions, which ACEs/trauma in a culturally and could be used for a future study involving a linguistically sensitive manner. We believe larger sample size. that this three-step process will result in parents/family members having adequate 4.1 Policy Implication levels of health literacy surrounding ACEs Studies have shown a strong and adequate levels of health literacy association between ACEs and chronic surrounding positive parenting to ultimately health problems, mental health problems, buffer toxic stress. We believe that the and poor economic outcomes in adults curriculum design for ACEs in this study is (Felitti et al., 1998). This study has shown an exemplar for other entities to follow, that information on ACEs could help buffer especially those serving low-income people

Copyright © 2019, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Thao et al. Archives of Psychology, vol. 3, issue 5, June 2019 Page 14 of 20 of color. However, we recognize that the not receive the intervention; as such, we curriculum was a short-term intervention, cannot make any causal inference. Our and further research is needed to investigate small sample size is also a limitation to be the long-term effect. In addition, this study addressed in future studies. did not include a comparison group that did

Table 2: Health literacy and Empowerment Three-Step Model for ACEs

Targets For Recommended Programs Intended Outcomes (1) Health Literacy Parent/family Based on the theme we identified of Adequate level of members “affirming the usefulness of the health literacy infographic information,” create surrounding culturally and linguistically sensitive ACEs information on ACEs utilizing words/symbols and other meaningful knowledge geared for specific populations (e.g., Latino, African American, and Hmong)

(2) Health Literacy Parent/family Based on the theme we identified Adequate level of members as “viewing those practices as a health literacy problem and recognizing their surrounding negative consequences,” create positive culturally and linguistically parenting competent parenting programs to promote healthy parenting practices

(3) Empowerment Parent/family Based on the theme of “feeling Adequate level of members empowered to seek resources to health literacy overcome ACEs consequences,” surrounding refer them to organizations ACEs to buffer addressing issues surrounding toxic stress ACEs/trauma

5. ACKNOWLEDGMENT Yumiko Aratani for the input, revisions, and guidance. Support for this study was provided by a grant from the Robert Wood Johnson Foundation Interdisciplinary Research Leaders program. Special thanks to Dr.

Appendix A

Jose is a 10-year-old boy who likes playing basketball with his friends. However, lately Jose has been feeling as if no one loves him. Jose’s father often drinks beer and yells at Jose when he is drunk. Jose’s mother has tried to stop her husband from yelling at Jose, but she often ends up in their fighting, and Jose feels as if he has no one to protect him.

Eve is a seven-year-old girl who enjoys drawing. She has a mother who cries and feels sad all the time. Eve’s mother feels fatigue almost every day and does not give much attention to Eve. Eve feels physically and emotionally neglected by her mother.

Justin is a third grader who likes playing with his young brother. His mother often gets angry at him and slaps him hard every time he misbehaves. Justin is usually scared of getting punishment when his mother is around.

Appendix B

1. How do you think children like Eve, Justin, and Jose will be when they are adults? Emotionally or physically?

2. Do you think they will be different from other children whose father did not drink and/or slap them or whose mother did not neglect or treat them violently?

3. Do you think Justin, Jose, and Eve can benefit from any type of help? If yes, what kind(s) of help? Probes used: help in their homes, in their housing community, or at school.

Appendix C

Educate parents on ACEs (15 minutes). We will show the ACEs infographics and explain the long-term health and mental health impact of ACEs.

The ACEs infographic in English, published by the Robert Wood Johnson Foundation (2017), is available online at https://www.rwjf.org/en/library/infographics/the-truth-about-aces.html.

Figure 1. ACEs infographic in Hmong Figure 2. ACEs infographic in Spanish

Appendix D

1. How do you feel about ACEs now that you know about them?

2. How do you think Eve, Jose, and Justin will be emotionally or physically when they are adults?

3. Do you think Justin, Jose, and Eve can benefit from any type of help? What kind(s) of help?

4. What kinds of services do you think can help children or families with ACEs?

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