Building Resilient Schools: A public health approach to address ACEs and support mental well-being

State: CT Type: Model Practice Year: 2019

The Farmington Valley Health District ( is a regional health department in Connecticut serving 110,000 in the ten towns, north and west of Hartford. The ten towns are categorized as suburban or rural and enjoy higher than average median household incomes when compared to the State. Twenty-two percent of the population is school aged (5-19). There are 9 independent and one regional school districts in the Farmington Valley. Mental health issues are emerging as priority public health issues among the populations served by FVHD including our school administrators and faculty who are seeing the negative impact of mental health stressors on school children, their educational attainment and social engagement. Schools who routinely collect data from student surveys (Developmental Asset Profile), are reporting increases in the proportion of students challenged or vulnerable with respect to 8 assets recognized as important for students to thrive including positive identity, commmitment to learning, social competencies, empowerment, boundaries and expecations (Canton survey). Anecdotally faculty and administrators are also perceiving increases in depression, social isolation, anxiety and stress among their student body. In 2015, the FVHD received a grant from the Prevention Institute, with funding from the Movember Foundation to implement a men's mental health initiative that in part focuses on, building communities that foster and support good mental health while building the resilient attributes of individuals that support good mental health. Recognizing the growing mental health challenges expressed by school age children, the link between mental health and social, emotional, physical health and educational outcomes and the opportunity for early intervention, FVHD partnered with the East Granby School system to develop year long programming called Resilience Grows Here. The overarching goal of the practice is to mediate the harmful effects of Adverse Childhood Experiences (ACEs) and childhood stressors to ultimately improve the physical, mental and social health over the lifespan by achieving the following objectives: Create a school community that understands, fosters, reinforces and models protective attributes of resilience among its students Establish a regular curriculum and dedicated programming for students focused on building their resilient skills that support good mental health Create broader community networks that understand the relationship between mental health and physical health and provide nurturing environments that support good mental health Empower staff with skills and confidence to support student mental health and strengthen positive relationships and resilient students and staff. A school-based program called Year of Resilience” was developed that includes on session per month in each grade and with all students. During the sessions, two facilitators/instructors (the FVHD Community Health Coordinator and a consultant) focus on a resilient attribute using exercises, team building and hands on activities. Resilient attributes are aligned with the Adverse Child Experience (ACEs) work and include: the ability to calm oneself, developing self-esteem, learning to self-advocate, trust, sense of belonging, developing friendships, expressing feelings, working as a team, experiencing success, giving back to community, experiencing failure and problem solving. In addition, the resilient attribute is reinforced throughout the month with recommended age appropriate books in the library, additional tips/tools for use in the classroom, visuals in the school and parent messaging that is sent home regularly. During the 2017-18 school year, FVHD piloted the year long program in partnership with the East Granby Middle School. During that year all East Granby middle school students (165) in grades 6 through 8 received the program. Because of the enthusiasm of the School Superintendent, Administrators and faculty, the program expanded to the East Granby High School and the Canton Middle School in school year 18-19 with additional inquiry from other schools in the FVHD. Evaluation during the 2017-2018 pilot year included post student evaluations and faculty key informant interviews. Students reported that they had been able to use the skills learned especially through improved communication, conflict resolution, dealing with problems, accepting differences and being able to ask for help. A focus group of faculty revealed that teachers noticed that students had developed a vocabulary around resilience and could articulate what that meant and why it was important. Teachers also reported that they observed more discussion on how to communicate, how to be better friends and specific skills were observed in situations particularly in the areas of conflict resolution.
According to the CT School Health Survey (2017), Youth Behavior Component, 27% of high school students surveyed reported feeling sad or hopeless almost everyday for 2 or more weeks in a row. In addition, 27% reported being teased for their weight, size or physical appearance. More than 20% reported being bullied on school property. Even more sobering is the fact that 13% of high school students reported seriously contemplating suicide. In addition to these self-reported stressors, Adverse Childhood Experiences (ACEs) are common. While we do not have CT specific data, according to published studies, approximately 48% of children have had at least one of the nine adverse childhood experiences. The CDC reports that almost two thirds of surveyed adults report at least one ACE and more than one in five reported three or more ACEs. ACEs include any type of abuse (emotional, physical or sexual) and household challenges including violence, substance abuse, mental illness, separation or divorce and incarceration in the first 18 years of life. A dose-response relationship between ACEs and a number of health outcomes including heart disease, smoking, stroke, diabetes, risky health behaviors and mental distress has been established. As local health departments struggle to address the challenges of premature morbidity and mortality associated with chronic diseases and emerging health issues associated with risky health behaviors, a focus on mental health, mental health stressors and the environments that support good mental health is imperative. This concept is promoted by CDC through Essentials for Childhood that emphasizes the importance of safe, stable, nurturing relationships and environments for children. The Resilience Grows Here school initiative was developed by the Farmington Valley Health District, in collaboration with our Resilience Grows Here Steering Committee (comprised of municipal officials, mental health providers, veterans, social workers and youth programming specialists) and school partners to mediate the impact of adverse childhood exposures and experiences by increasing the resilient attributes and skills of school aged children while also promoting a nurturing school environment that reinforces the use of resilient attributes, recognizes the importance of ACEs and creates a social norm that fosters acceptance, understanding and security. Eventually, FVHD hopes the RGH school program will be embedded into all nine of our independent school systems at the elementary, middle and high school levels. (See Sustainability) Currently the program is being offered in 2 middle schools and one high school reaching 420 students. The East Granby school system served as the pilot in 2017-2018 in the middle school and expanded the programming to the high school in 2018-2019. The Canton middle school implemented the program during the 2018-1029 school year and modified work is being done in the high school. Prior to this initiative, most schools report that they have no ongoing or systematic approach to dealing with ACEs or building resilient attributes. Schools report that professional development workshops and trainings are provided periodically on restorative practice, student centered learning and social/emotional learning but there is nothing widespread or ongoing that focuses specifically on mediating the harmful effects of ACEs and other life stressors through student skill building. The Year of Resilience program is a creative use of existing tools based off Mind Matters Secondary, Kids Matter Primary and Early Childhood Programs from Australia's Flinders University. These programs were used by RGH program director in her years teaching in international schools with great success. Adaptability of these programs as age appropriate while also defining and reinforcing a common language of resilience provides a mental health supportive framework that can be built upon as the students progress through the school years. The consistent focus on resilient traits as well as broad life skills, sets a stage for mental wellbeing to become an everyday normal focus, thus reducing stigma and normalizing requests for support and assistance. The broad and longitudinal concepts of this program have been researched and evaluated with successes including better national testing results in schools, better staff understanding and ability to support the emotional and social development of students, improved staff's ability to recognize students facing mental health challenges, improved student/staff trust and relationships, which is a protective factor for children. Student temperament was also assessed to be less reactive and more approachable as a result of the program. Kids Matter is a Flinders University Evidence Based program that focuses on Promotion, Prevention and Early Intervention. The program focuses on risk and protective factors and is grounded in the ACEs principals and was supported in development by Beyond Blue a major Australian National Mental Health Initiative.
The overarching goal of the practice is to mediate the harmful effects of ACEs and childhood stressors to ultimately improve the physical, mental and social health over the lifespan by achieving the following objectives: Create a school community that understands, fosters, reinforces and models protective attributes of resilience among its students Establish a regular curriculum and dedicated programming for students focused on building their resilient skills that support good mental health Create broader community networks that understand the relationship between mental health and physical health and provide nurturing environments that support good mental health The concept for the practice was initially born out of a men's mental health initiative focusing on veterans. In research and early work in that arena, FVHD recognized that veterans who faced the most significant mental health challenges during their transition back to civilian life were much more likely to have entered the military having experienced adverse childhood experiences, long before their military careers began. During our early work on the veteran's mental health grant, we were simultaneously hearing from our school and community partners about youth mental health challenges. This spurred a more detailed review of ACEs. To achieve the overarching goal and objectives of this initiative, FVHD first leveraged its position as the health department to engage partners across multiple disciplines. The Steering Committee for the veteran's mental health initiative is comprised of veterans, mental health professionals, town leaders, social workers and youth programming specialists. This group was instrumental in beginning to frame the issues and potential strategies for looking more up stream at youth. School based partners including the East Granby Middle and High School Principals, guidance counselors, school psychologist and faculty were instrumental in program development and delivery. Despite a very compact school schedule, administrators in East Granby committed the time and staffing resources for the program. This includes 1 hour of class time per month and one hour of drop in” time per month per grade. While the actual sessions are delivered by two individuals, the teachers actively participate in all the session exercises and activities, engaging with students in a more social and supportive way and demonstrate that they too are learning new skills to deal with stress, decision making etc. The cost to develop the year-long curriculum is estimated at $20,000 and includes consultant costs (specialist in youth programming) and FVHD Community Health Coordinator time to build and foster working relationships with the partners, review curriculum and assist in delivery of the program. Material costs are estimated at $500/year/grade.
An external evaluator, Institute for Community Research, was engaged to assist with overall evaluation. Both process and some outcome evaluation measures have been measured with ongoing efforts to collect more outcome measures. We were able to successfully implement 10 months of programming for all students in grades 6-8 in the first year. In the second year we saw the program expand to the high school and an additional middle school in the District with additional inquiry of at least two other systems. Upon completion of the first year, the Institute for Community Research collected qualitative data from both student participants and faculty and school staff. The following is an excerpt from the external evaluators report: Students in each grade also were asked to respond to the following open-ended questions/statements: How have you been able to use the skills that you learned in this program? What was the most important thing that you learned in this program? My mental health is important because… My physical health is important because… The following themes stand out for each question/item. How have you been able to use the skills that you learned in this program? Through improved communication - I have talked to my parents about my problems” To enhance friendships When dealing with problems and challenges - I was depressed this year because of bullies and other problems. This program taught me how to overcome problems and overall be a better person.” With family and friends - In conflicts at home I reflect back to some [of the] skills.” Using communication skills in dealing with disagreements with friends. When dealing with problems and challenges - I have been able to use the skills that I've learned in this program by using them when I face tough situations and challenges.” Importance of being able to ask for help Dealing with aspects of everyday life - Use responsibility skills to manage time wisely and get things done Through effective communication Student noted ability to communicate better in front of crowds What was the most important thing that you learned in this program? Communication How to communicate feelings Empathy How to ‘fit into other peoples' shoes' Communication - Importance of expressing yourself; Useful when solving conflicts with peers Seeking help/dealing with problems - The most important thing that I learned in this program was probably [that] it's okay to ask for help.” Resilience - What it means and how to be resilient; how all topics presented were connected to resilience Understanding/helping others - Seeing things from others' perspectives Teamwork Communication - Importance of proper communication; how to be sure that you're communication clearly to friend/peer Seeking help/dealing with problems - The most important thing that I've learned … is seek for help because I can't do everything by myself.” Being resilient - Resilience isn't just withstanding something, it's helping others, being kind, communicating, team player Understand/helping others - Understanding that everyone is different; Everyone has strengths and weaknesses My mental health is important because… It affects all aspects of life - Affects everything you do; Affects ability to enjoy life Mental health affects health and well-being of self and others - Affects relationships with friends; affects ability to help others; it affects loved ones Several students connected mental health to harming self or others. For example, to be able to make good choices so as not to harm self; so you don't become depressed and want to take your life; so as not to do something bad” or something you'll regret; being upset or angry can cause you to harm yourself or others. This also will be addressed in a more intentional way in coming year's program. It decreases stress, anxiety - Without good mental health would be scared, sad and not able to do anything It affects the ability to function in everyday life - It keeps me ready for any challenge I have to face.”; one's mental health affects everything on your life Important to care of self - how care of self, how feel about self Connected to physical health - Being upset mentally can affect” emotional, physical health Determines ability to make appropriate decisions, choices My physical health is important because… Keeping safe from disease Related to long and happy life Spoke of weight/obesity in context of physical health - I will die soon I am super fat” Students also connected physical health to mental health; how one affects the other. It affects ability to do things/function in daily life It affects your future - Not taking care of body will result in problems at later point in time Related to self-esteem/self image, including concern over body weight - Being healthy and loving myself the way I am is very important for a healthy lifestyle.” Relationship of physical to mental health - how care of self, how feel about self It affects ability to function in everyday life - Need to be healthy to do things that need to be done Affects longevity - Important for long and happy life Related to well-being and positive self-image - Look better and be more confident; affects how viewed by others Faculty We had the opportunity to conduct a focus group with 7 EGMS faculty to help evaluate the acceptability usefulness and impact that the Year of Resilience from the teacher perspective in the classroom setting. Teachers noticed that students have developed a broader vocabulary. For example, they began to use the word resilience” more frequently and, more importantly they are using it with more understanding and can elaborate on what it means. Students seem to remember more the interactive, movement sessions. They refer to topics and lessons learned in the monthly sessions and bring what they have learned back to the classroom and incorporate it into daily life. This reflects student responses to the end of year survey items mentioned above. For example, teachers noted more discussion on how to communicate and how to be better friends, and communication and skills were observed in situations of conflict resolution. Teachers shared a variety of ideas when asked how RGH and the Year of Resilience curriculum might better serve them in the classroom setting. Examples included: Integrate monthly themes into the classroom setting, within the context of the specific subject and activity being taught. Incorporate the monthly topic into morning announcements. Students seem to really enjoy the use of skits or acting to introduce or address monthly topics. Perhaps include more of this type of activity, or even a drama day” when students can perform for one other. The Principal offered to do email blasts that would offer tips to teachers from the RGH curriculum. Create an RGH/EGMS blog that would be an opportunity to share what and how students are learning in the YoR sessions. Start a book club and reading list for students to enhance the YoR learning experience. Coordinate with English/social studies curriculum on themes so RGH can try to time its classes to tie in with those themes. Engage students in journaling. Classroom teachers can use them to focus in on topics throughout the year and could designate specific time in their schedules for students to do journaling. The journals could be kept in lockable bins secured by the teachers. Possibly create a website for teacher resources that relate to the YoR curriculum. Teachers suggested the following topics to be added to the YoR curriculum: Advocacy; Consequences; Decision making; Friendship; Bullying/mean behavior; Asking for help for others - how to ask for help, provide phrases that could be useful, and how to use them appropriately; Help phrases refusal skills, how to step in, how to ask for help, getting out of difficult situations. Other suggestions some of which would help to engage parents/guardians included: A book club for teachers/parents, focusing on resilient traits; Parent evenings incorporating topics on raising resilient parents; A resilience workshop for teachers; An educational evening for parents run by the students that might include what your parents need to know about resilience” with information tables and activities. Students would have the opportunity to re-teach” what they have learned in Year of Resilience sessions. Prior to each monthly session, students would be asked to write/draw/express in a creative way what they expect that month's topic to entail. Students are energized, not disruptive, when returning to class after RGH sessions Identify one session as an Education Camp” with facilitated stations that highlight resilience attributes. In the current year, pre and post tests are being done to evaluate knowledge and attitudes regarding the resilient attributes covered over the course of the school year. In addition, ongoing qualitative data will also inform how skills are being applied and any changes in programming.
During the Spring 2019 school year, FVHD staff, consultants and school partners will be developing a Train-the-Trainer model that will allow existing staff within the school system to administer the program. FVHD, within its existing community health programming resources will be able to provide training workshops, technical support and evaluation oversight to school systems interested in implementing the Year of Resilience. We will also be developing marketing materials for our schools to emphasize the value of addressing mental health challenges and fostering environments that support good mental health and the role of the Year of Resilience in accomplishing this goal. A key lesson in this work has been the appreciation of the extent to which the school day is already programmed to meet the ever changing academic outcomes. However, there is an increasing recognition by school administrators and others that academic achievement is much harder to achieve when students are stressed, under mental duress and lack the resilient characteristics that allow them to more effectively deal with stressors, ask for help and communicate their needs. By providing school administrators and faculty with tools that can easily be integrated into the school environment, classrooms to reinforce the resilient attributes, it becomes a social norm and helps to reinforce positive and constructive behaviors. Faculty offered many suggestions after the first year regarding integration into their classrooms suggesting that there was overall buy in for ongoing engagement in this work.
At a NACCHO conference