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"The report distills cutting-edge learnings from a variety of scientific disciplines in a way that seeks to be accessible to a broad array of readers. The scientific standards used to develop the report include systematic and targeted searches using electronic research and grey literature databases of English language articles, with preference given to systematic literature reviews, metaanalyses, and replicable findings in multiple, large-scale, and/or well-designed studies from reputable sources. Where possible, such well-supported evidence is presented and related methodologies are described. Where not available, supportive or promising evidence, emerging from fewer studies and/or studies with smaller or otherwise less representative samples, are presented instead. These instances are flagged as such, and are presented only when better quality evidence does not yet exist and because they still represent findings of emerging interest and relevance to the field.” (p. xvii)

“Advances in functional neuroimaging, developmental neurobiology, genomics, epigenomics, transcriptomics, proteomics, and metabolomics have begun to decode the complex mechanisms by which early adversity can become biologically embedded and influence life-course health and even the health of the next generation.” (p. 12)

“Project Cal-Well of the California Department of Education (CDE)1416 and the Healthy Environment and Response to Trauma in Schools (HEARTS) program of the University of California, San Francisco (UCSF),1417 are two case studies in California that are presented to provide a snapshot of how primary, secondary, and tertiary prevention of toxic have been translated into school settings.” (p. 196)

"Between 2005–2006 and 2017–2018, there was a 47% relative increase in the number of public schools nationwide with one or more security staff with the authority to arrest students.1411 When public schools increasingly rely on school resource officers to discipline students at school, school-based arrests go up.1412 Combating these systems using restorative justice techniques that emphasize redirection and de-escalation tactics, and prioritize time in the classroom, can minimize re-traumatization and mistrust and better support students’ long-term physical, social-emotional, and cognitive growth.1408-1410” (p. 195)

ACEs Aware Grants program: “Awarded 150 grants to 100 organizations across the state in three categories—Provider Training, Provider Engagement, and Communications—to expand the reach and impact of the ACEs Aware initiative” (vii)

“Historically, the national child welfare system has directed almost all its attention and resources to tertiary prevention efforts for children who have already experienced abuse and/or neglect (i.e., to prevent recurrence). In California, the Department of Social Services (CDSS) is the administrative agency that oversees the child welfare system. The Office of Child Abuse Prevention (OCAP) within CDSS has recently championed a more overt primary prevention focus (i.e., preventing abuse and neglect before they occur) by addressing the major drivers of child welfare involvement: poverty, unaddressed mental health challenges of caregivers, substance use, and a parental history of child abuse.1198 “ (p. 163)

“ACEs Connection—an information-exchange catalyst and social network community of practice in the worldwide ACEs and toxic stress movement—had been working in partnership with the EfC Initiative to identify and document ACEs-related activities (e.g., trainings or events) at the local level. In this effort, ACEs Connection developed a mapping tool for displaying ACEs and trauma-informed organizational activities geographically and by sector.1529 Three California counties (Fresno, San Diego, and Santa Barbara) have been piloting its use to help track their local ACEs-related work.” (p. 285)

“Resilience is the ability to withstand or recover from stressors, and results from a combination of intrinsic factors, extrinsic factors (like safe, stable, and nurturing relationships with family members and others), and predisposing biological susceptibility.42,98,99. Of note, while the term resilience is often considered in the mental health and behavioral domains, scientific advances in understanding of the impact of stress on neuro-endocrine-immune-metabolic and genetic regulatory health compel advancement of the definition of resilience to also include these domains as well.” (p. 18-19)

Primary prevention: “Public education campaigns to raise awareness of ACEs and toxic stress, and to arm the public with science-based solutions for reducing the impact of ACEs on children and adults, paired with policy strategies to support safe, stable, and nurturing relationships and environments; Access to high-quality mental and physical healthcare, including family-centered treatments; • Enabling opportunities for stress-buffering activities such as access to nature, mindfulness activities, physical activity, and sufficient and high-quality sleep; Providing high-quality early and ongoing learning opportunities, including for social-emotional learning, executive function skills, healthy relationship skills, and responding to challenges; Cross-sector and sector-specific training in trauma-informed tools, approaches, and strategies for all providers engaging with children and families; and public health surveillance and policy-oriented applications of population-level indicators of exposure to ACEs and impacts of toxic stress.” (p. xxx)

Secondary prevention: “There is a consensus of scientific evidence that early detection and early intervention improves outcomes related to toxic stress. 6-9,23,31,603,704” (p. xxx)

Tertiary prevention: “Tertiary prevention involves interventions beyond the clinical setting. This report outlines how each sector—healthcare, public health, social services, early childhood, education, and justice— can contribute to healing the harmful effects of ACEs and toxic stress. To truly achieve practice and population health transformation, coordinating a cross-sector network of highly effective and transformative referral and service options is imperative.” (xxxii)

“Public health efforts should target preventing or reducing environmental factors that worsen toxic stress physiology, such as exposure to lead and air pollution” (p. 155)

“While vulnerable communities experience greater stressors and are therefore at higher risk, it is important to recognize that ACEs happen in every sociodemographic group, and that they are often under-recognized in upper-income and non-minority groups; therefore, universal approaches are necessary.” (p. 171) 

“Exposure to ACEs can also set up transmission of health risks across generations by altering gene expression (epigenetics) in parents to be, which can affect the development and health of their children, and future generations to come.32,33 Intergenerational transmission of toxic stress physiology can also perpetuate and exacerbate socially rooted inequities in health, achievement, socioeconomic mobility, and mortality.16,29,35,36,60,62” (xviii)

“While there currently exist no widely agreed-upon clinical diagnostic criteria for toxic stress, a number of biomarkers associated with neuro-endocrine-immune-metabolic disruption are under investigation.332-334” (p. 30)

“More research is needed to precisely identify clinically useful biomarkers to diagnose and follow risk of toxic stress longitudinally, as well as more specific therapeutic targets.” (xviii)

“Policy- and systems-level efforts to prevent ACEs and toxic stress also depend on the awareness and engagement of the general public and governmental decision-makers. The “political will” to implement pro-child, pro-family policies and budgets is influenced by social norms about the status of children and the loci of responsibility for their well-being. The dominant public narrative about child abuse and neglect, for example, has been characterized by an individual focus on “bad” parents and government interference. Based on research findings, the FrameWorks Institute has created a social counter-narrative that can help engage the public in understanding early child development as it applies to child abuse and neglect prevention, understanding potential policy directions, and supporting solutions to pressing problems.” (p. 148)

“Lead is an example of a specific environmental exposure that interacts with the toxic stress response, in that the effects of lead exposure are more powerful in children who are experiencing toxic stress, and vice versa. Lead exposure disrupts a child’s ability to recover from early life stress. Both animal and human studies have identified toxic stress and lead as affecting shared neurobiological systems, including the hypothalamicpituitary-adrenal (HPA) axis, as well as the frontal cortex and hippocampus (parts of the mesocorticolimbic system). Exposure to lead in early life can result in potentially lifelong alterations in the HPA axis and accentuate physiologic responses to stress.169 Exposures to both lead and toxic stressors (like ACEs) together result in enhanced neurotoxicity.170 Exposure to lead also acts synergistically with stress during pregnancy and early childhood, and is associated with decreased IQ, increased incidence of attention-deficit/hyperactivity disorder (ADHD), antisocial behavior, preterm birth, lower birth weight, and juvenile justice involvement.” (p. 24)

“Exposure to ACEs and the associated dysregulation of the immune system involved in toxic stress can combine with breathing polluted air to exacerbate negative asthma-related outcomes.” (p. 27)

“As another example, in utero exposure to both stress and air pollution can increase oxidative stress, which may affect the development of the fetal lungs, including increasing airway inflammation and adverse simplification of the normally complex structure.235,236 In fact, an increased risk of asthma was found in children co-exposed in utero to fine particulate matter (PM2.5 ) and maternal stress (OR 1.15; 95% CI, 1.03-1.26) during the phase of lung development when many of the peripheral airways important in asthma develop (canalicular phase).” (p. 27)

            This past spring break (2016), on a Monday night while at home, I responded to a motor vehicle accident as a Good Samaritan. The accident happened at approximately 19:00 hours on my street in Blackstone, Massachusetts. My father was on our front porch when he heard a car barreling down our back country road which has a long straight away before taking a sharp turn. Before the impact he knew that the driver would not anticipate the curve fast enough at the speed he was traveling. Sure enough, there was a loud bang and the sound of a car rolling over, which I could hear from inside the house (approximately ¼ mile from crash).

I grabbed both of my personal first aid kits and a flashlight while my father called emergency services. I walked to scene with my father and younger brother. I sped walked and arrived at the crash site first.

The vehicle was a ‘90s sedan that went straight into a telephone pole, which broke like a toothpick, and rebounded backwards and flipped 90 degrees on its left side. Parts of the car, tools, and glass were on ground, airbags deployed. There was a car seat in back, and for a moment I thought a child but it was just clothing. Front right tire was up inside front passenger compartment. Hazards flashing. Driver window was rolled down. No people in the car.

My brother and father directed traffic on either end of the crash site. They almost certainly prevented at another crash by a car who didn’t see the accident but saw my brother flag them down with his light.

I saw man standing 20’ from crash site, talking to people in a gold SUV. When I arrived I start asking medical questions and the people in the SUV leave – they were by standards who pulled up but left after I started taking over. The man in question appeared to be a lower/middle class white/Hispanic, male in his 30s. He was driving an older car with lots of tools in the back which were now all over the road. Our neighborhood is a small country community and I know he was not from our neighborhood. I assumed he was some kind of mechanic, bases on tools in car. He was wearing dirty jeans and stained hoodie. He was definitely a blue-collar worker. He may have been from downtown Blackstone which is largely lower middle class and blue collar, or he may have been from Woonsocket, Rhode Island, which is known as “the Detroit of Rhode Island”.

As I tried to obtain basic medical information from the patient, it was apparent he had an altered mental status, and did not appear to understand fully what was going on. I am not certain if it was alcohol and/or drugs as for safety reasons I did not get close enough to the patient/suspect to tell. He was ambulatory and verbal. The interesting part of our conversation was to the best of my ability as follows:

“Are you sure you’re okay? Umm yeah. Are you hurt anywhere? I’m fine. [I did visual inspection of patient using flashlight which revealed no major injuries other than minor cuts from airbag]. [He starts to edge away from scene]. You should wait for ems to check you out. Wait, you’re right! I might die?! You appear to be okay externally but things like internal bleeding, and a full assessment could reveal other problems. Naaaa [turns and starts to walk away down street]”

I attempted to convince the patient to wait on scene but he was going through several mode swings during my interactions with him from fear, anxiety, agitation, and anger. While I was talking to the patient, the first officer from the neighboring town arrived on a motor cycle. I informed the officer at the scene of the situation about the patient/suspect fleeing the scene. The officer took note of it and continued to work to secure the crash site. Another officer arrive from my town from the west. I informed the same and he stated that he would need me to make a witness statement and proceeded to the crash site. A third and fourth officer arrived together the same time as two ambulances (indicated because of rollover) from the east. One of them told me again that they would need a witness statement.

I met back up with my dad and brother who were no longer needed to control traffic with law enforcement on scene. Neighbors had started coming out to see the commotion. We were all talking near the scene while waiting for officers. Finally one of the officers asked another officer if he should go look for the suspect. He left approximately 20 minutes after my last contact. I never spoke with the arriving EMS as they came from the east and I was on the west of the accident but officers told them that the patient was missing. Eventually multiple officers and cars were out looking for patient/suspect but was not found as far as I am aware. I finally was given the chance to give my testimony which, to the best of my knowledge, mirrors this report. After reading out loud in front of the officer and my father and brother to confirm accuracy, the officer asked me something very strange. First, he asked me to add what the suspect was wearing (which I had forget to include), but then he also asked me to state that I saw the suspect drive into the telephone pole and that I smelled alcohol on the patients breath. Neither of these things were what I told any of the officers and ran counter to my testimony as written. I include the suspect’s clothing description but I did not add the second mention and stated that I had not witnessed those things. After my report I left the scene with my brother and father.

Some of the policies and procedures relevant to this case were: scene safety, dealing with aggressive/combative patients, and HIPPA did not apply to me as a bystander so I gave full testimony including medical status to the officers.

After reflecting on the education I received and didn't receive, there are a few things that would have allowed me to be better prepared for this incident. How do I convince patients to stay on scene? When do you give up? I wish my EMT class was a little better scene on safety training. Being distracted by the emergency at hand, I did not truly take into account the fact that the power lines were live and drooping with half of the telephone poll pulling on them. Only supported by the next and previous poll but not drooping more than 3’ from normal, more than 15’ from ground, and 10’ above vehicle. Reflecting on it, I did not really consider the threat as I should have, and neither did the officers on scene. I don’t understand why it took so long for police to search for the suspect who could have had major medical issues. Should I have followed suspect/patient alone? When is a citizen arrest allowed/appropriate? Should I have asked for the badge number of the officer who asked me to misrepresent the truth on an eye witness testimony? What is the process to do that anyway? If I had the answers to these questions I feel I may have been able to provide better assistance, but then again perhaps not.

This report was published by the Minnesota Department of Human Services.