Building Strong Brains in Tennessee

Introduction

The 2012 data in front of the Deputy Governor of Tennessee were clear: This was a serious public health issue and something had to be done. Two out every five adults in the state had experienced multiple severely negative events in childhood, multiplying their risk for serious health problems like heart disease and diabetes. The related health care costs were unsustainable—and the toll on community and individual wellbeing was unacceptable. Health and human services systems needed to retool, and quickly, to address the implications. And to put the state on the path to a better future, major shifts were needed to make sure that things were different—better—for children living in Tennessee today.

There was sufficient political will to move forward—the governor and cabinet members were persuaded by developmental scientists and public health researchers, who had discovered about the long-lasting effects of adverse experiences in early childhood, and wanted to act. But the work would be hard, involving far-reaching changes to the health, justice, and education systems. And the messaging challenges were significant. It would be all too easy for a public conversation about better systems of support to devolve into blaming parents and holding them exclusively responsible for their children’s wellbeing.

“ The problem with the way adverse childhood experiences are usually talked about is that there is a lack of context that helps people see root causes and realistic solutions.”

“The problem with the way adverse childhood experiences are usually talked about is that there is a lack of context that helps people see root causes and realistic solutions,” says Richard Kennedy, the Executive Director of the Tennessee Commission on Children and Youth. “A story about tough times traumatizing kids makes it all about individual children and families—the blame-the-victim and pull-yourself-up-by-your-bootstraps kind of thing— with no role for policy, community or government.”

Systems leaders and other change agents face a similar dilemma when they try to align systems with science. They know it’s vital to listen to what research has to say—but they also know that it’s just as important to listen and learn from those with different kinds of knowledge and expertise. And then there is the fact that the science rarely speaks for itself.

This challenge led to a pioneering collaboration between the State of Tennessee, the ACE Awareness Foundation, and the FrameWorks Institute—work that has changed not only the conversation, but systems and outcomes in the state.

Building Strong Brains Tennessee created a powerful mix of science and storytelling to frame how environments and experiences in early childhood shape life outcomes—and an equally powerful system of spreading that story. As a result, residents in every Tennessee county have learned about the potential lifelong impacts of early childhood adversity. Children are more likely to have educators who know why and how to buffer young children from the effects of traumatic events. Public servants—from lawmakers to law enforcement—better understand how public policy can shape health, wellbeing, and resilience. State agencies and other systems that serve children and families have both new direction and new resources to support their work.

As in any collaborative project, many organizations and people contributed to the success of this work. But, says Kennedy, “I really believe that the communication research and messaging strategies from FrameWorks are the key to what has happened here in Tennessee. Framing is the secret sauce that has infused everything we have done.”

This impact brief traces the way that reframing has catalyzed better outcomes for children and families. Shared, powerful frames translate science in ways that shift people’s perspectives on social issues—which opens the path for better policy and practice.

The Link Between Early Experiences and Lifelong Health

In the late 1990s, a landmark study revealed a powerful relationship between traumatic events in childhood and people’s physical and mental health in adulthood. Known as the Adverse Childhood Experiences (ACE) Study, and conducted by the Centers for Disease Control and the health maintenance organization Kaiser Permanente, this study asked adult patients to disclose some negative events that they may have experienced before the age of 18. Researchers asked specifically about 10 experiences—things like losing a parent, or witnessing or experiencing domestic violence—and then looked to see how the number of adverse childhood experiences tracked with a wide variety of adult health outcomes.

Some of what they found was not surprising: People who had experienced abuse or neglect as kids were more likely to have mental health problems as adults. But other findings were striking—like the realization that there was a clear, graded relationship between early adversity and physical health. One serious event in childhood seemed to have few or no observable long-term consequences. But multiple forms of adversity in childhood predicted multiple health problems in adulthood. For example, children who experienced four adverse childhood experiences were twice as likely to be diagnosed with cancer than those who had no significant experiences of childhood trauma.1 The more adverse experiences people had in childhood, the more likely they were to be diagnosed with asthma.

These findings reverberated throughout public health, social services and other sectors nationwide—and prompted more studies. In Tennessee, a 2012 survey found that more than half of the population had experienced at least one adverse childhood experience (ACE); one out of five residents experienced three or more; and in more than a dozen counties, a staggering 42 percent of the population experienced two or more ACEs.

“This research left no doubt that if we wanted to improve health and wellbeing in Tennessee, we had to figure out how to address ACEs,” says Barbara Nixon, founding board member of the Memphis-based ACE Awareness Foundation. The foundation started to fund work in Shelby County, where Memphis is located, while interest in addressing the issue was also growing in several other parts of the state.

“ This research left no doubt that if we wanted to improve health and wellbeing in Tennessee, we had to figure out how to address ACEs.”

Jennifer Drake Croft, Director of Early Childhood Well-Being for the Tennessee Commission on Children and Youth, recalls realizing just how far-reaching ACEs were: “Adverse childhood experiences affect everyone and impact anything you care about,” she says. “If you care about local economic development, health care, criminal justice reform, social determinants of health, institutionalized racism, social justice, or even the safety of yourself and family, there is a connection. ACEs are the root cause of many of our most seemingly intractable issues— diseases, mental illness, and social problems.”

Against this backdrop of interest, Governor Bill Haslam and First Lady Crissy Haslam hosted a summit in 2015. A “who’s who” of influencers—from government, philanthropy, business, and the faith community to the news media, top academics and state Supreme Court justices— gathered in Nashville. Leaders were briefed by world-class neuroscientists, who explained how early experiences shaped children’s brains and bodies in ways that had a long-term effect. And they heard from FrameWorks, with an emphasis on how important it was to communicate that science carefully.

At the end of the day, then Deputy Governor James Henry stood up and delivered a challenge. “What we’re going to do in Tennessee is change the culture,” he announced. Henry called for a high-ranking member of the Departments of Children and Youth, Education, Health, and every other child-serving department to serve on a public sector steering group to make sure that the science of early adversity was integrated into their agency’s work. And he asked them to work in collaboration with nonprofit organizations. Key members of this partnership included the Tennessee Commission on Children and Youth, ACE Awareness Foundation, Annie E. Casey Foundation, and the FrameWorks Institute.

Learning the Science— and How to Share It

With a research-backed framing strategy in hand, the next step was to begin to spread it. Rather than devoting significant resources to communications—say, an expensive, top-down public awareness campaign—FrameWorks advised a strategy of investing in communications capacity.

The public-private partnership allowed for an expansive initiative. Says O’Neil: “Building Strong Brains was a powerful project because it equipped so many credible messengers with a shared, science-based story that they could adjust and adapt to their contexts and communities.”

Across a period of several months, 150 leaders attended a series of symposia, which featured some of the nation’s top experts on children’s development and adverse childhood experiences. Convenings focused on three topics:

• Science: The latest research on the way that adverse childhood experiences can affect health and development throughout the lifespan
• Practice: Examples of science-informed early childhood programs and policies that other cities and states have created to improve education, workforce development, and human services
• Implementation: The practical side of how to drive evidence-based change in areas like early learning and family services, so that “what we do” is aligned with “what we know.”

With a common sense of the science that needed to be shared with colleagues and communities, leaders continued their learning journey in “FrameLabs,” intensive trainings that equipped them to use the recommended framing strategies.

“FrameWorks was so strategic—they did an excellent job of putting together a process that informed and engaged people around the state,” says Nixon of the ACE Awareness Foundation. In the process, she added, FrameWorks staff also helped bring people together around not only a shared story but a shared mission. “I felt like people came to this project to work on a shared mission, instead of everybody coming to the table with their own agendas. Part of that was because the FrameWorks presence made it a bigger, more neutral territory,” Nixon adds. “FrameWorks made it clear that reframing is about what we were all trying to do together.”

Reframing is something that organizations can and must do together—which can overcome the pull of competing agendas.

To make the capacity-building approach sustainable over time, FrameWorks designed a “train the trainers” initiative for the Tennessee Commission on Children and Youth to implement. This work continues to this day, bringing the science to educators, nurses, and others working with children in Tennessee. To date, approximately 1,000 professionals have been trained—who, in turn, have reached more than 40,000 other professionals.

Suddenly, It’s Everywhere

With such a significant investment in communications capacity, it’s no surprise that people are hearing and thinking more about early childhood in Tennessee.

“In every corner of the state, people now have a much greater awareness of the importance of the first years of life and the consequences they have for everything we care about,” says Nixon. “They are learning that adverse childhood experiences not only impact health but also people’s ability to function in life: in school, on the job, in healthy relationships, and in parenting. There is a ripple effect of things that happen into adulthood.”

“ In every corner of the state, people now have a much greater awareness of the importance of the first years of life and the consequences they have for everything we care about.”

There has also been a ripple effect on the way state resources are allocated.

“Governor Bill Haslam surprised us in the spring of 2016 when he put $1.25 million into his budget proposal for ACEs-related activities,” reports Mary Rolando, who oversees this work as ACEs Innovation Director in Tennessee’s Department of Children and Youth. When Haslam left office in 2019, that funding was increased to $2.45 million. It was also established as a recurring budget item, ensuring the work could continue under new leadership. Since then, Rolando and her colleagues have awarded grants across different regions of Tennessee to ensure it would continue to be a statewide effort.

For example, in rural Green County, the agricultural heartland of Appalachian East Tennessee, a farm and food education center received support to work with young people who had experienced adversity. Rural Resources teaches disadvantaged youth “how to raise animals and care for plants,” Rolando explains, which supports social and emotional skills. And, recognizing that the effects of early adversity can dampen employment prospects, the project also gives youth the opportunity to gain professional skills and develop plans for their own businesses.

In Nashville, Belmont University received funding to develop a core curriculum about child development and trauma that now reaches all nursing, occupational therapy, physical therapy, social work, and public health students. Says Rolando: “This means our future health professionals will view child development and adversity through a common lens. We’re going to have a workforce who knows how important this issue is, and how their work can help to prevent and address ACEs.”

All told, Building Better Brains Tennessee has supported more than 35 funded projects designed to improve outcomes for children and communities. Efforts have trained educators, police officers and community workers—and many of these, Rolando adds, “have become sparkplugs for other good things to happen.” After all, she emphasizes, the focus in all of this work goes beyond raising public awareness. “It asks, ‘How do you lead from where you are to prevent and address early adversity? How does internalizing the frame change the way you see the work we have to do together?’ ”

The Power of Collective Effort

The success of Building Strong Brains speaks to the power of a collective impact approach that involved government champions, philanthropic leadership and financial commitments, and trusted local leaders who could move things forward. All agree that a strong evidence base for action was essential in coordinating the efforts of so many sectors and players. That evidence base included the scientific insights brought by leading authorities—and also the research-based approach of FrameWorks, which was able to tap decades of expertise in both the subject matter and proven communications strategies, as well as a commitment to positive social change.

“When you bring in outside experts, it can be a delicate balance to get it right,” observes Nixon of the ACE Awareness Foundation. “Success has to do with being authentic. And, I felt the FrameWorks team was very authentic and caring and put in the work to quickly understand our state. My impression was that they were just as passionate about what we were trying to do as we were.”

Whether other states will adopt a model like this one remains to be seen but there has been growing interest in Tennessee’s leadership, says Kennedy. And when the US House Oversight and Reform Committee held a hearing on the long-term consequences of childhood trauma in July 2019, Deputy Governor James Henry—who issued that initial challenge at the 2015 symposium—was there to testify about the success of the work in Tennessee.

It is work that Mary Rolando, who continues to oversee the project for the state as ACEs Innovation Director, can only describe as remarkable. “It’s a movement now,” she says.