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The 3 minus T spproach: building meaningful community connections by designing neighborhoods conscious of the effects of adversity focused on the healthy development of all children

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The 3 minus T spproach: building meaningful community connections by designing neighborhoods conscious of the effects of adversity focused on the healthy development of all children

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Content CREATING ADVERSE CONSCIOUS ENVIRONMENTS THAT BUILD MEANINGFUL
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The 3 minus T Approach: Building Meaningful Community Connections by Designing
Neighborhoods Conscious of the Effects of Adversity Focused on the Healthy Development of
All Children

Nereida Carrasco
University of Southern California

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The 3 minus T Approach: Building Meaningful Community Connections by Designing
Neighborhoods Conscious of the Effects of Adversity Focused on the Healthy Development of
All Children
Executive Summary
Worldwide, the impact of violence is intertwined with the development of children across
their lifetime through immediate, lasting, and multigenerational effects. The landmark study by
the Center for Disease Control and Kaiser Permanente coined childhood experiences of adversity
involving forms of abuse, family hardships, and forms of violence as Adverse Childhood
Experiences (ACEs). The past 30 years of investigation and science has provided insight on the
lifetime behavioral, health, and well-being impacts for children through data, surveillance and
identification of patterns and experiences of violence. Evidenced Based Practices (EBPs) have
been found to be effective forms of interventions for children experiencing mental health
symptoms and behaviors as a result of violence, but they do not prevent ACEs (CDPH, 2017).
Prevention has been identified as a significant key to ending childhood death, physical injury and
the impacts of psychological trauma of ACEs (California Department of Public Health (CDPH),
2017). Yet, public policy and privately and publicly funded programs have focused on
administering behavioral and mental health treatment to children only after severe impairments
in their life (American Academy of Social Work and Social Welfare (AASWSW), 2015).
Consequently, this results in failure to identify numerous children with the symptoms and/or
behaviors of violence exposure and ACEs. To support children who experience violence the
burden of healing requires a new perspective that involves multi-systematic population-based
approaches within the community (Decker et al., 2018).
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The 3 minus T project offers an opportunity to prevent the impacts for children under the
age of 18 who experience and/or witness ACEs by reducing the incidence and prevalence of
behavioral health problems through the use of a public health approach within the community.
The 3 minus T project involves three phases. The first phase will involve collecting
epidemiological data within a city to provide an understanding of the forms of violence and the
locations in the city that are impacted at a higher rate. The second phase will involve training
community providers (law enforcement and medical professionals) and community members on
practical skills which can be used in neighborhoods impacted by violence and/or ACEs. This
second phase will allow for training participants to apply their understanding, recognition, and
response to adverse events through neurobiology, self-regulation, and practical skill
development. An Attitudes Related to Trauma Informed Care (ARTIC) scale and Stanford
Professional Fulfillment Index will be used to assess attitudes towards trauma, professional burn-
out rates and professional fulfillment. The measurement tool will be re-administered at 3 and 6-
month intervals. The third phase will involve community groups for children and
adults/caregivers employing the use of sociotherapy groups to provide arenas for practical skill
development. A Self-Reporting Questionnaire (SRQ -20) will be used to measure the symptoms
and behaviors of individuals impacted by trauma in the community. The project will use focus
groups at 6 months follow up to allow for community members to share how the intervention has
transferred to real-world settings.
The following paper will address the opportunity that exists to ensure a healthy
development for all children under the age of 18 by using science and data driven approaches to
end the intractable problem of violence exposure in childhood through ACEs. The aims of the
project are to determine whether a public health approach using a population-based intervention
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can address adverse childhood experiences through prevention focused trainings on practical
skill development and community groups within neighborhoods impacted at a higher rate (to)
BY experiences of violence. The creation of the Social Connections training is innovative as it
seeks to prevent ACEs and focus on practical skill development for providers who come into
contact with individuals who have experienced ACEs in an effort to reduce the impacts of ACEs.
The use of a multi-systematic population-based approach provides the next step after trauma
informed care as it focuses on creating healed, strong, and empowered communities with present
and engaged community members willing to prevent and not just be provided treatment for
ACEs.
Conceptual Framework
Statement of Problem
For over 30 years, the United States has been working towards cultivating the health and
well-being of members of society who witness and/or experience violence. Yet, worldwide the
exposure to violence whether witnessed and/or experienced is a life-threatening public health
problem for all individuals, but especially for children under the age of 18. The landmark study
by the Center for Disease Control and Kaiser Permanente recognized forms of adversity in
childhood such as abuse, family hardships, and violence as Adverse Childhood Experiences
(ACEs). In 2015, 16 million US children and youth within at-risk communities experienced
adverse events that ranged from “frequent socioeconomic hardship, parental divorce or
separation, parental death, parental incarceration, family violence, neighborhood violence, living
with someone who was mentally ill or suicidal, living with someone who had a substance use
problem or racial bias” (National KIDS COUNT, 2017; Center for Disease Control (CDC),
2016). Accordingly, data has revealed that twenty-two percent of U.S. children, 16.4 percent of
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California children and 16.7 percent of children within Los Angeles County have experienced
two or more ACEs in their childhood (Kids Data.org, 9/29/2018). (Data) SOCIAL science
through data collection, surveillance, and research on the patterns and experiences of violence
has provided insight to the detrimental lifelong injury, disability, and death that impacts children
under the age of 18 (Center for Disease Control (CDC, 2016). Examination of data on ACEs has
documented the association between the number of ACEs and the lifetime impacts on physical
health, mental health, risky behavioral health choices, low life potential, increases in potential for
re-victimization, and premature death (WHO, 2016, CDC, 2016). Yet, public policy continues to
provide behavioral and mental health treatment through privately and publicly funded programs
to children only after severe impairments in their lives (American Academy of Social Work and
Social Welfare (AASWSW), 2015). Consequently, this results in a failure to identify numerous
children with the symptoms and/or behaviors of violence exposure and ACEs. As violence is
preventable, there is a need for a multi-systematic population-based approach within the
community that provides a new perspective to preventing and healing ACEs in children under
the age of 18 (Decker et al., 2018).
Literature and Practice Review of Problem and Innovation
Violence disrupts the lives of one billion children each year who experience some form
of violence resulting in two hundred thousand deaths for youth 10-29 years of age (World Health
Organization (WHO), 2016; Mikton et al., 2016). Adverse Childhood Experiences (ACEs)
impact children under the age of 18 at a rate of twenty- two percent in the U.S., sixteen-point
four percent for California, and sixteen-point seven percent throughout Los Angeles County
(Kids Data.org, 9/29/2018; National Kids Count, 2018). In the state of California, forty percent
of children under the age of 18 and in the County of Los Angeles forty-nine percent have
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experienced one or more ACEs (National Kids Count, 2018). In the U.S., 7.5 million children
under age 18 experience a non-fatal injury resulting from violence in their home, school, and
community environments (CDC, 2017). The U. S. Department of Health and Human Services
reported that 674,000 children under the age of 18 were victims of child maltreatment in 2017 as
a result of child abuse and neglect (U.S. Department of Health Services, 2017). Children 12
years and older were victimized at a rate of 11.8 per 1,000 children and children with disabilities
were victimized 29.5 per 1,000 children at 2.5 times higher rate to other children (Bureau of
Justice Statistics, 2017). The Global Health Report 2014 indicates that one in four children will
experience physical abuse. Nationwide, children were found to have residence in out of home
placements due to reasons of safety and juvenile justice at a rate of 410,459 in foster care and
54,148 in juvenile detention/correctional and/or residential facilities (National KIDS COUNT,
2017; Sickmund et al., 2015). The U.S. Census Bureau identified that fourteen percent of
children as of the last census count were living in a neighborhood that was above thirty percent
of the federal threshold poverty level.( I AM NOT SURE WHAT THIS MEANS) 5.1 million
children reported having one parent incarcerated in jail or prison in their childhood with highest
rates being found among African American children (National KIDS COUNT, 2017).
The spectrum of violence is defined by the WHO (2002) as “the intentional use of
physical force or power, threatened or actual, against oneself, another person, or against a group
or community, which either results in or has a high likelihood of resulting in injury, death,
psychological harm, maldevelopment or deprivation” (p. 5). Violence may impact, “all age
groups, race, ethnic, [religion, culture], socioeconomic class, sexual orientation, gender, and
geographic regions” (SAMHSA, 2017, pg. 7). Children may experience violence through direct
and/or indirect involvement as a victim, offender and/or even witness in homicide, assault (e.g.:
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bullying, fighting, dating violence); physical, emotional, and sexual abuse; school violence;
serious accidents; illness or medical procedures; displacement from their homes; war; terrorism
and political violence (CDC, 2016; SAMHSA, 2017, pg. 35). Physical violence to children such
as pushing, shoving, hitting, or slapping increased their likelihood for exposure to other forms of
violence and victimization (Afifi et al., 2017).
Mental health providers define violence exposure as emotional and psychological harm
after an event that was physically and emotionally harmful, or life threatening that resulted in
impairments to mental, physical, social, emotional, and spiritual areas of daily functioning
(Substance Use & Mental Health Services Administration (SAMSHA), 2012, p. 7). The National
Institute of Justice (2017) indicated that the experience of violence results in mental health
symptoms and behaviors such as posttraumatic stress disorder (PTSD), panic, suicide, social
withdrawal, and physical symptoms (e.g.: insomnia, appetite disturbance, lethargy, headaches,
muscle tension, nausea, and decreased libido (National Institute of Justice, 2017, pg. 1). Inner-
city youth have reported symptoms of aggression, anxiety, and/or depression after exposure to
violence (Gorman-Smith & Tolan, 1998). A study by Chen et al. (2017) found that the
development of depression for children under the age of 18 who are exposed to violence
develops at different rates depending on witnessed versus experienced violence events as they
enter adulthood. In addition, this study found that further research was needed regarding the
progression and development of depressive symptoms (Chen et al., 2017). Youth who experience
exposure to violence may be driven to make choices that impact their future through higher
engagement in gang activity, perpetration induced trauma, higher symptoms of disassociation,
and emotional numbing (Moed, Gershoff, & Bringewatt, 2017; Kerig et al., 2015).
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The landmark epidemiological study by the Center for Disease Control (CDC) and HMO
Kaiser Permanente (Kaiser) in 1995 brought light to the threats of health and safety of children
under the age of 18 who experience adversity in the forms of abuse, family hardships, and forms
of violence. Adverse Childhood Experiences (ACEs) was the term formulated to describe
childhood experiences involving, “frequent socioeconomic hardship, parental divorce,
separation, or death, parental incarceration, family violence, neighborhood violence, living with
someone who is mentally ill or suicidal, living with someone who had a substance use problem
and/or racial bias (National KIDS Count, 2017); CDC, 2016). The CDC-Kaiser study contained
limitations as the respondents were not representative of the population as a whole. The study
also used convenience sampling by using the only one Kaiser facility to collect participants and
minimized questions regarding adversity (Boullier & Blair, 2018). The study was beneficial as it
provided insight to multiple systems (e.g.: medicine, academics, state legislature, judicial, and
social sciences) surrounding the number of ACEs and the impacts across a lifetime (Felitti,
2017). In addition, it created awareness that many systems were not focused on ACEs and have
been slow to incorporate these insights into all system levels (Felitti, 2017). Lastly, the study
allowed for the medical profession to gain knowledge on the benefits and importance of using
questionnaires to inquire about sensitive subjects and use of listening with implicit acceptance
during medical evaluations (Felitti, 2017).
The experience of increased number of ACE experiences has been associated with a
lifetime of impacts on physical illness, mental health, risky behavioral health choices, low life
potential, increases in potential re-victimization, communicable and non-communicable diseases,
lack of success in academics and employment and premature death (Riese et. al.; 2016; Afifi et
al., 2017; WHO,2016; CDC, 2016). In addition, lifetime impacts to quality and healthy
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relationships with other individuals, medical conditions (e.g.: heart disease, diabetes, cancer,
lung disease, and/or obesity), substance use, unsafe sexual practices, and infection with sexually
transmitted infections and/or HIV/AIDs (WHO, 2016). Children exposed to violence across a
lifetime will be predisposed to higher levels of conditions such as heart disease, diabetes, cancer,
lung disease, or obesity, substance use, unsafe sexual practices, and infection with sexually
transmitted diseases and/or HIV/AIDS (WHO, 2016). In addition, experiences of adversity have
been linked with risky health behaviors, chronic health conditions, low life potential, and early
death (Center for Disease Control (CDC), 2016). The psychological, biological, and social
symptoms of ACEs have also identified that “memory loss, depression, suicide attempts, cancer,
autoimmune problems, domestic violence, and isolation” (Bennett, 2017, pg. 18).
As children grow, adversity begins to create challenges within systems meant to enhance
their potential to grow. Multiple exposures to violence in households predisposes families to
minimize the impacts of violence exposure (Efevbera et al., 2016). The Maternal and Child
Health Bureau (2012) found that African American/Black and Hispanic children reported in
greater rates than other racial groups of living in environments that were sometimes and/or never
safe (Maternal and Child Health Bureau, 2012). The effects of exposure to violence for children
can be seen through decreases in academic potential. Children who experience violence are at-
risk of having learning gaps that may impact them into later years because learning is a
cumulative process that builds on prior academic knowledge (Burdick-Will, 2016). Frequent
incidents of victimization for children by third grade are associated with lower test scores in
reading, mathematics, and science than for children not exposed to violence (Musu-Gillete et al.,
2017). Positive behavioral support has been found to improve the structure of discipline in
school settings for children exposed to violence (Sugai & Horner, 2002). Maternal suicide
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attempts were found to diminish the educational performance in adolescents which impacted
their wellbeing and future opportunities (Geulayov, Metcalfe, & Guennell, 2016). Juvenile
Justice Systems understand that when children are subjected to violence it results in impacts to
choices to their future. Higher levels of exposure to violence, perpetration-induced trauma, and
higher symptoms of disassociation and emotional numbing were found in gang involved youth
(Kerig et al., 2015)
Protective factors for children exposed to violence have been documented to reduce the
detrimental effects by building strong relationships with family, peers, and their communities.
Children who have access to positive peers, supportive relationships, cohesive neighborhoods,
and organizations with strength-based policies are able to build resiliency (DiClemente, 2016;
Jain et al., 2011). Higher emotional functioning skills in children who experience violence
correlated with the ability to better cope with adverse experiences and reduced generalized
anxiety (Burgers & Drabick, 2016). Nurturing environments which are reliable, responsive and
consistent provide healthy psychosocial, cognitive, and physical development for children and
allow for healthy pregnancies, families, schools, and communities (Fuemmeler, 2017).
Neighborhood cohesion was found to be a protective factor for males living within high violence
areas (DiClemente, 2016). Supportive parental relationships were found to prevent direct
violence involvement due to reducing the risk of youth being exposed to dangerous situations as
well as less engagement in substance use and/or aggressive behavior (Culyba, 2016; Moed,
Gershoff, & Bringewatt, 2017; Ozer, Douglas, & Wolf, 2015). Harsh parenting relationships
were found to pose a greater risk for youth who were more likely to be away from home and in
places where violence might occur (Moed, Gershoff, & Bringewatt, 2017). The evidence
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suggests that supportive environments are necessary to ensure a healthy development for all
children.
Professionals within the community can create a safety net by using multiple strategies to
improve the outcomes for children exposed to violence. Positive police interactions have been
documented to reduce risk for delinquency and provide better police perception and contact by
individuals (Slocum, Wiley & Esbensen, 2015). Community professionals who understand
protective factors and interact in a manner that builds trust and creates safety are beneficial for
children impacted by violence (Van der Kolk, 2014; Leitch, 2017). A research study identified
that youth impacted by violence expressed being willing to discuss and be linked to mental
health providers for treatment if compassionate primary care physicians were to create a
relationship with open communication (Riese et al., 2016). The various systems providing care
for those experiencing violence appeared to have an incomplete set of the skills and strategies for
assisting traumatized clients even among those most felt to be most knowledgeable (Donisch,
Bray, & Gewirtz, 2016). Yet, primary care physicians reported having lack of knowledge and
ability to inquire with youth about exposure to adverse childhood events (Riese et al., 2016).
Youth expressed that at times it is challenging to report violence or adverse childhood events due
to lack of trust, discomfort and/or feeling that these events are personal problems (Riese et al.,
2016).
The public health model is a framework that attempts to provide the maximum benefit to
the entire population by ensuring their health, safety and well-being (Center for Disease Control
(CDC), 2019; WHO, 1998). The four-step process of this model involves a scientific method that
can be applied to violence by defining and monitoring of problem, identification of the risk and
protective factors, development and testing of prevention strategies and assurance of adoption
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throughout the population (CDC, 2019). Since 1980, the U.S. Public Health Service has worked
towards creating healthier communities by using this public health approach towards violence
prevention. The use of this scientific method has assisted public health in creating prevention
focused evidenced based approaches that have led to an increase life expectancy of more than 30
years by addressing the root causes that lead to disorders (CDC, 2017; Brownson, Fielding &
Maylahn, 2009; Morris et al., 2017). Just as public health uses input from multi-disciplinary and
diverse sectors such as health, medicine, epidemiology, sociology, psychology, criminology,
education, economics, justice, policy and private sectors which may help to address diseases, the
same strategy can be applied a problem such as violence (Dahlberg et al., 2002; CDC, 2019).
The public health system appears to be the organization that provides the largest potential to
implement a population-based violence prevention plan (Purtle, 2017). The barriers to the public
health model involve funding as community-based approaches or efforts to create new treatments
for patients are not regularly funded by government, private, and philanthropic sectors (Ellis &
Dietz, n.d.). The facilitator for the public health department is the vision of healthy people and
communities and promoting physical and mental health through assessment, policy development,
and assurance in preventing disease, injury, and disability (CDC, 2017). A limitation involves
the reluctance to implement a population-based approach in mental health promotion due to lack
of experience with mental health (Purtle et al., 2017).
Data has been the driving force towards realizing the large impacts of violence on
children and communities. The Center for Disease Control (CDC) has worked towards ending
violence through epidemiological studies, collaborating and encouraging professionals to be
involved in violence prevention efforts to reduce the death and disability associated with injuries
outside of the workplace (CDC, 2016). As of 1992, data has been collected through the Youth
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Risk Behavior Surveillance System (YRBSS) to monitor the risk behaviors of youth which
include violence related behaviors which can lead to death and/or disability (CDC, 2016). In
1995, the first ACE study created scientific research through design and creation of social
programs to bring attention to ACEs and the impacts of childhood neglect, abuse, and
dysfunctional households into adulthood (Leitch, 2017). A limitation of the current data involves
the lack of victimization data for children 12 years and younger as national databases only track
children 12 years and older (Bureau of Justice Statistics, 2016). In addition, (as of) THE 2016
redesign of the survey sample resulted in data not being comparable to previous years due to
2010 decennial census, state, and local victimization future reports (Bureau of Justice Statistics,
2016).
In the United States, the economy of adversity involves a weak social safety net which
results in poor health outcomes, less protection for vulnerable populations from adverse
socioeconomic conditions, risky health behaviors, and fragmented health systems (Thakrar et al.,
2018). Every decade, the U.S. Census fails to count more than one million children of color
under the age of five from low-income and immigrant households which results in exclusion
from federal dollars for social programs and services and proper apportioning of legislative seats
within states (The Annie E. Casey Foundation, 2018). Every year, the cost of ACEs is estimated
to be one billion in healthcare, law enforcement, and lost productivity which results in $27
billion in underage drinking, $60 million in delinquent behavior, and $247 billion in treatment
services and lost productivity (WHO, 2016; AASWSW, 2017). Due to weak safety nets, U.S.
children in comparison to other wealthy nations from 2001 to 2010 had a higher risk of death
resulting in seventy-six percent greater risk for infants and fifty-seven percent greater risk for
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children under the age of 19 (Thakrar et al., 2018). In addition, this study estimates that the U.S.
might have prevented an excess of 600,000 infant and youth deaths (Thakrar et al., 2018).
Trauma informed approaches have been found to decrease further victimization of
children. The research shows that understanding trauma and the impacts on an individual is
benefit to children even while there is no current agreement on the specific practices and policies
(Lopez at al., 2017; Branson et al., 2017). The best practices for trauma informed care
organizations and communities involve realizing the prevalence of trauma, recognizing the
impacts on the daily lives of individuals in all organizations and putting knowledge into practice
(Substance Abuse and Mental Health Services Administration (SAMHSA), 2016, pg. 11).
Trauma informed care practices also incorporate neurobiology to be able to understand and
conceptualize the impacts (of) THAT trauma may trigger IN the brain and body when they
encounter stressful events. While public service providers felt that they were knowledgeable
regarding trauma informed practice there appeared to be a large gap in IN THE QUALITY
OF(variation) of their skills and strategies in response to traumatized clients (Donisch, Bray &
Gewirtz, 2016). An innovative trauma informed intervention is Sociotherapy an emerging
intervention which uses strengths and resources in the community to adopt healing and growth
by refocusing trauma events from an individualistic to a social healing perspective (Richters,
Rutayisire, & Slegh, 2013). A healing centered approach allows for healing through a holistic
approach involving culture, spirituality, civic action and looks past trauma informed to a
collective healing (Ginwright, 2018).
Neurobiology allows us to understand trauma from a scientific perspective which
describes how the body can create change due to the impact of trauma. The complexity of the
brain allows it to be open to interaction with its environment and the ability to respond and adapt
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to environmental changes and create connection to other systems (Applegate & Shapiro, 2005).
Research has also shown that “spatiotemporal imprinting of the experience of terror and
dissociation is considered to be responsible for the intergenerational transmission of trauma”
(Mahajan, 2018; Schore, 2001). In addition, a paradigm shift is needed that looks towards
healing and recovery for adult survivors as a tertiary prevention that is necessary for primary and
secondary prevention of exposure in children and adolescents (Dube & Rishi, 2017; Dube et al.,
2013). According to Ridout et al. (2017) individuals who have experienced trauma may have
telomere shortening which has been found to create mutations to genes and genetic changes. The
neurobiology advances provide significant insight that the impacts of violence and adversity for
children does not end with treatment, but can be genetically transmitted to future generations and
continue the negative impacts of ACEs.
Social Significance
Currently, the exposure to violence cross cuts multiple state, federal, public and private
entities which address the injury, disability, and death by different methods, but none are able to
provide intervention at all levels of a child’s life. Legislation surrounding violence exposure has
been enacted as of 1974 with the Juvenile Justice and Delinquency Prevention Act (JJDPA) and
again in 2016 with the Supporting Youth Opportunity and Preventing Delinquency Act of 2016,
H.R. 5963 (U.S. Congress, 2016; National Association of Counties, 2017; US Senate, 2017). In
addition, the Trauma Informed Care for Children and Families Act was proposed in 2017 (U.S.
Congress, 2016; National Association of Counties, 2017; US Senate, 2017). The National
Conference of State Legislature (NCSL) reported that legislation creates a challenge as it does
not create a clear and identified plan with collaboration between education, juvenile justice,
mental health, and public health systems to address the exposure of violence for children.
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Siloed systems exist with narrowed and less comprehensive systems to address the
exposure to ACEs. Mental health systems use evidence-based practices which have been shown
to improve the mental health issues of children who have experienced violence. Mikton et al.
(2016) found that to reduce forms of violence, knowledge and prevention efforts required to be
rooted in evidence-based violence prevention models implemented in low and middle
communities with high violence areas. The multidimensional nature of violence requires further
research and development of strategies by primary health care providers towards understanding
how to prevent and intervene to create support systems. And, victimization can be prevented
when linguistic and culturally appropriate approaches are used to understand the person who has
experienced trauma (Lopez et al., 2017). Given that violence exposed children tend to have
higher stress levels when entering adulthood which may require additional identification and
monitoring to not engage in serious violence (Heinze et al., 2017). The challenge with
individualized mental health treatment is that termination of treatment occurs before completion
of treatment and many treatment modalities are geared towards specific incidents and not
multiple exposures to violence (Efevebera et al., 2016). The research demonstrates that there is a
continued need to be able to create strategies to provide a neutral and safe spaces for children
and individuals that have been impacted by violence through adverse childhood experiences by
multi-systematic community-based approaches.
Conceptual Framework with Logic Model Showing Theory of Change
The logic model for 3 minus T project identifies the development and implementation of
a multifaceted adverse conscious care approach involving a population-based model through
three phases. The logic model seeks to create a linear chart of inputs, activities, outputs and
outcomes for the 3 minus T project by attempting to solve the problem of children witnessing
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and/or experiencing adverse childhood experiences in their home, school, and/or community
(Appendix A). The resources (i.e.: inputs) needed to develop and implement the 3 minus T
project involves a public health system, local public health department, community partners,
community members, law enforcement, and health care providers. The program staff will
involve one health worker and one licensed clinical social worker. The activities are assorted
across three phases. The first phase will involve a community-based disease investigation
assessment using available data within the City of Pasadena, community interviews in the areas
of higher violence (i.e.: activities) which will lead to increase in identification of community
members that experience symptoms/behaviors of trauma and safe spaces to discuss ACEs in high
violence areas which (i.e.: outputs) will develop a public health epidemiology approach to
identify adverse impacted communities. The initial outcomes are to decrease perception
regarding trauma impacts as indicated by Self Reporting Questionnaires (SRQ-20) (i.e.:
outcome). The second phase activities involve development of an adversity training (i.e.: 3 minus
T: Social Connections) which will be an 8-hour training. The outcomes involve AN increase in
safe connections, access to practical skill training, and an increase in empathy and fulfillment for
community providers and community members (i.e.: outcome). The last phase will involve the
activity of a community sociotherapy groups to be held within the community for 10-12
community members over the course of 15 weeks in community spaces. The outcomes of the
activity involve change in stigma surrounding mental wellness, community-based approach
healing, advancement of strong social engagement systems within areas of high violence, and
community capacity building towards management of adverse impacted community members,
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The long-term impacts involve a community conscious of adverse childhood experiences and
violence impacts, the creation of a healthy development of children and families, and practical
skill building surrounding ACEs.
Problems of Practice and Innovative Solutions
Proposed Innovation and its effect on the Grand Challenge
To improve the outcomes resulting from Adverse Childhood Experiences (ACEs), the 3
minus T project will be used to create a community conscious of the effects of adversity by
addressing Adverse Childhood Experiences (ACEs) through a prevention practical skills
development project focused on the whole community. The first phase of the 3 minus T project
is focused on using epidemiological data already available from the community to identify areas
within the City of Pasadena where children are experiencing the high rates of violence through
the use of a public health approach. The second phase will involve practical skill training for law
enforcement and medical providers and community members which live or work within these
high violence areas. The Creating Social Connections 8-hour training will provide information
regarding neurobiology, spectrum of ACEs and trauma, and practical skills to regulate the brain
and use with community members and children. The third phase will involve a 15-week
sociotherapy groups for children and adults in the community led by trusted community
members. The adult/caregiver group will involve open discussions on safety, trust, care, respect,
new roles, and memory of emotions. The children’s group will involve discussion on healthy
growth and development, guilt and acceptance of imperfections, responsibility, teamwork, risks
of choices and a chance to improve their lives, self-identification, learning gratefulness, and
gaining new experiences and fun events throughout group sessions (e.g.: field trips).
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Trauma prevention programs have been created to ensure quality programs that will
create positive development and public safety (Ford et al., 2016). Evidence has been found that
early psychological intervention aimed at beginning treatment within three months of the
distressing event may prevent or treat presenting and ongoing mental health disorders and/or
distress (Saltini et al., 2017). The refocus of trauma from an individual perspective to a social
trauma perspective creates further connection to strengths and community resources that allow
for healing and posttraumatic growth (Richters, Rutayisire, & Slegh, 2013). Knowledge based
trainings have been created surrounding the impacts and ways to assist community members in
managing adverse childhood events. The use of neuroscience knowledge allows for trauma to be
a biological response as every human being is wired to respond to threat and fear because of the
nervous system that helps manage the regulation of physical, emotional, and cognitive
functioning (Leitch, 2017; Cozolino, 2002; van der Kolk, 2014). Professionals benefit from
interacting with children and youth to build trust and create safety by understanding the positive
and resilient factors (Van der Kolk, 2014; Leitch, 2017).
The incorporation of multifaceted approaches to healing trauma allows for community
providers to move beyond identifying the spectrum of trauma witnessed and/or experienced to a
strength-oriented perspective (Leitch, 2017). The public health approach is ideal for this as it has
encouraged long term strategic plans to assist in identifying youth who are greatest at risk from
violence (Sood & Berkowitz, 2016; Malti & Averdijk, 2017; Slutkin, 2017). The project will
provide a multifaceted approach to ACEs by involving the whole community and creating
partnerships towards healing within high violence areas without requiring the children within the
community to suffer severe mental health impairments. The project builds on trauma prevention
projects that were created to ensure quality programs that create positive development and public
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safety (Ford et al., 2016). By providing psychological intervention aimed at prevention, the
project aims to prevent psychological distress by beginning treatment before an adverse
childhood experience. As early psychological intervention within the first three months of a
distressing event may prevent presenting and ongoing mental health disorders and/or distress
(Saltini et al., 2017). The 3 minus T project refocuses adverse experiences from an individual
perspective to a social trauma perspective which creates healing and posttraumatic growth
through connection to strengths and community resources (Richters, Rutayisire, & Slegh, 2013).
Professionals who gain skills surrounding understanding positive and resilient factors are
able to build trust and create safety for children under the age of 18 (Van der Kolk, 2014; Leitch,
2017). The combination of prevention, knowledge, and practical skill development allows for
communities to prevent the consequences of adverse childhood experiences. By creating
communities that foster healthy and positive relationships with children under the age of 18 we
create thriving communities that will provide a healthy development for all children and youth
across their lifespan. The project also builds on identifying practices that effectively assist in
managing the incidence, prevalence, and multigenerational impacts of ACEs.
Views of Key Stakeholders
In California, a key stakeholder in violence prevention is the California Department of
Public (h) Health (CDPH). On June 6
th
, 2018, the CDPH gathered over 50 public health
professionals from local public health departments, public health leaders, and local champions
across the state to establish a violence prevention initiative. As a leader within the Pasadena
Public Health Department Social and Mental Health Department, the author was invited to attend
this initiative meeting. The initiative discussed public health approaches to violence prevention
by identifying priorities for a shared public health agenda and documented summary and notes
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within the Violence Prevention Initiative: Public Health Convening Summary available within
the CDPH website (CDPH, 2018). The themes discussed throughout this meeting involved root
causes, public health messaging, building local capacity, gun violence, and community trauma
and resilience (CDPH, 2018). For the purpose of this project, the community trauma and
resilience themes were most relevant. Stakeholders within this meeting identified potential
strategies to combat violence in California:
1. A need for the experiences of adverse communities to frame and harness assistance
from all sectors to identify changes required in policy, systems, and environmental
changes.
2. Address and prevent community trauma that involves all aspects including law
enforcement and mass incarceration.
3. Increase ways to create trust building in communities that are impacted by poverty,
lack of affordable housing, and trauma.
4. Emphasize assessment of community assets and growth of resilience.
5. Create involvement of community and youth.
6. Nurture community engagement and grow social cohesion.
The small break outs provided an opportunity to discuss the overall work of organizations,
innovative efforts, creating stronger partnerships, and making public spaces available to all
across age, income, race, and culture. The other sections involved strategic planning with
communities through engagement and community capacity building as well as funding and
policy change. The discussion regarding innovative public health violence prevention initiatives
brought about a key innovation of moving from a trauma informed care approach to one of
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healing centered engagement that involves a holistic and humanistic framework to support
children impacted by ACEs.
The first step was to use the community input provided in the 2016 Health Needs
Assessment of Greater Pasadena which is the first joint report for the Greater Pasadena area with
combined efforts from Huntington Hospital and the Pasadena Public Health Department (PPHD).
This community input was sought to allow for insight on the health status and needs of the
residents of Greater Pasadena. The focus groups involved inquiring with community members
regarding 10 semi-structured key informant interviews to be able to identify significant
community health issues. The interviews allowed for identification of community members that
were knowledgeable in the health of the community. These community members were then
asked to provide further feedback surrounding the design of the health assessment and to attend a
large stakeholder meeting. These meetings provided input that the top health needs in the City of
Pasadena were healthy foods, dental care, mental health, affordable housing and access to care.
The second input gained was the top quality of life challenges involving local government,
access to care, affordable housing, public safety, transportation, education, nutrition/obesity
prevention, and cultural competency. These community meetings identified areas of need
surrounding limited access to health literacy, lack of funding for health, challenging social-
political environments, and bureaucracy in local government.
Community group interviews identified the following barriers within the community:
need to connect and collaborate to better promote information, seeking support from local
government, knowing that information is power and community members are underpowered, and
Pasadena has a set culture of this is how it should be. The groups identified that vulnerable
populations in the City of Pasadena involved Spanish speakers and persons of color, people
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living in poverty, residents living in the northwest Pasadena area, children/youth, and people
exposed to trauma or with mental health conditions. Community group also identified strengths
involving such as health interventions, residents, city council/local government, health
organizations, and resources, local organizations and resources, and Pasadena school district.
The community participants also identified that there was not enough mental health providers
serving children and that there might be some barriers (e.g. liabilities of working with children
and language barriers).
A focus group was provided to discuss the, 3 minus T, project which engaged community
members and providers in testing and feedback to gain the knowledge from multiple
stakeholders regarding the potential of the project to be effective in the community. Community
members identified the following: the need to engage other community providers when we think
about the community such as schools, medical offices, community centers, DPSS offices, and
other community agencies. The knowledge that any form of prevention and intervention was
beneficial as the exposure to violence left them numb and without knowing what to do. The
participants identified their thoughts and feelings regarding ACEs and violence within their
community. Community members expressed that there were specific concerns about the project
because of the identification of community networks that would assist in getting people involved
in the project, the experience of children of color who may experience more violence in their
lifetime, and concerns about what occurs if children were discovered to have had an adverse
childhood experience when going through the project. Community providers explained that
ACEs are challenging to the public health and to the community and stated that it would be
beneficial to create more community awareness.
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The project was also discussed within the University of Southern California in a 723
Design Laboratory for Social Innovation class with doctorate level students through the use of
the Semantic Environment activity through a virtual academic classroom environment. The
purpose of the activity was to identify whether a community-based approach to prevent ACEs
would be beneficial. The activity provided key takeaways surrounding the challenges of
collaboration within multiple providers, further community work would be needed for project to
be implemented, and the ability to identify the correct individuals for the project would be key
towards the success of the project. The other knowledge gained from completing this activity
involved understanding how to phrase and create questions that were beneficial and elicited
discussion within participants.
Pasadena community-based organizations (CBO) were provided with information
surrounding project by emails with training proposal and accompanying book. The Community
based organization explained that the project was worthwhile and valuable to the community and
suggested the project would be beneficial. A second CBO expressed that the use of the training
and training book allowed for the topic to feel more manageable and approachable. This CBO
also explained that the training was similar to a training already provided by them (e.g. Trauma
Stewardship) with differences in (using) THE WAY THAT THEY WERE USING IT . The CBO
also wanted further description regarding the neighborhood setting and why it was important for
the intervention to be focused on neighborhoods. The CBO provider also identified that a key for
this project was inclusion of humor and jokes as part of the training as individuals often forget
that joy and laughter are part of well-being and healing. The CBO provider also had questions
regarding the use of the word victim in the infographic used to provide information to the
community as well as the age group for the identified infographic.
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Pasadena Public Health Department (PPHD) staff were asked about the infographic and
training proposal. A Division manager expressed that community interventions create a benefit
for families and children in the northwest section of the City of Pasadena because of the limited
access to mental health programs not focused on severe impairments. The manager went on to
discuss how the infographic would be a good way to provide the northwest part of the City of
Pasadena community with information regarding ACEs and provide information surrounding
how to impact health equity and healthful lifestyles of healing. A staff within the PPHD
expressed that there is a need for all community providers to respond to attend a training like this
especially for those who respond to emergencies within the community. An epidemiologist
expressed the opinion that the project was worthwhile and appeared to be the next step after
gaining knowledge surrounding trauma informed care. The epidemiologist reported that the
training proposal created an opportunity for practical skill building that could be implemented
city-wide, but would require to be piloted to ensure to work out the initial challenges of
implementation of the training.
City of Pasadena Police Lieutenant was provided with the project information by e-mail
including infographics and training proposal and book. The information provided expressed that
that there was always a need to address ACEs. The infographic surrounding neighborhood
involvement was discussed as an engrained need that every community member should have. A
suggestion was also made regarding environmental design and how colors and lighting can also
affect emotional responses to surroundings, feelings of safety, and livability issues. A need was
expressed to involve natural surveillance, natural access control, territorial reinforcement,
security, fencing/walls, lighting, artwork, color, and internal documentation.
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The 3 minus T project took into consideration practical limitations and responded to their
concerns by changing language, adjusting the colors within the infographics and making
information more visually enticing to read. The multiple phases incorporated involvement within
multiple stakeholders who provided input regarding the identified activities and need for work in
high violence areas. The project also had challenges from not being able to incorporate ideas
such as environmental design, stakeholder engagement with other programs for implementation,
and involving other larger systems. The project hopes to look towards incorporating this in the
future.
Evidence and Current Context for Proposed Innovation
Currently, there continues to be lack of identified practices that treat children exposed to
violence prior to severe functional impairments (AASWSW, 2017). Violence interventions are
concentrated within specific violence types and symptoms due to being developed from medical
care, mental health, and/or public health paradigms which at times do not relate well into real
world settings (Ford, 2017; Schultz, 2017). The 3 minus T project seeks to assist communities in
being able manage the impacts of ACEs from a public health population-based approach. The 3
minus T project aligns with the logic model by attempting to use ACE science in order to
enhance knowledge on ACEs and practical skill development prior to impacts from ACEs. The
project will hope to be able to start with community providers and move to education and private
sector trainings to assist in helping to understand employees and the benefits to their overall
wellbeing. The 3 minus T logic model creates outcomes that are specific to preventing ACEs. As
ACE science has become more widespread it appears to be creating an understanding that it is
beneficial to treat adverse experiences in childhood instead of adulthood. As the project attempts
to also address compassion fatigue and fulfillment it also allows for gaining new skills,
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enhancing health, and reducing mental health from all community members and providers in
high violence areas. While there is a benefit to this project to allow for collaboration, capacity
building, and create a adverse conscious community. In addition, the creation of integrated
project and not siloed programs would create more inclusive spaces within our community.
The identified facilitators to the project would be that as the public health department has
actively implemented projects through surveillance, assessment, planning, training, stigma
reduction campaigns, and policy advocacy it appears there is an opportunity to create a
population-based intervention (Purtle, 2017). The project proposes that a partnership with the
public health department can be mutually beneficial. For this reason, the 3 minus T project may
be able to assist in being able to identify the multiple levels of susceptibility for children under
the age of 18 who may experience multiple forms of violence through the creation of strategic
plans (Sood & Berkowitz, 2016; Malti & Averdijk, 2017). National Policy on youth violence has
identified that collaboration is important within systems of education, juvenile justice, mental
health and public health to support comprehensive prevention projects that engage the
community in changing attitudes and behaviors (National Conference of State Legislature
(NCSL), 2010).
Comparative Assessment of Other Opportunities for Innovation
The first opportunity involves collaboration between organizations also creates some
challenge as current policies do not have direct support for evidenced based practices that ensure
public safety and positive development (Slutkin, 2017; Ford et al., 2016). The collaboration of
multiple systems may allow for gaining new skills, better health, reduction in trauma
symptomology as well as a decrease stigma. As the project moves forward, there may be the
opportunity to show how organizations can work towards the development of positive and
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healthy environments that help public safety. Given that, National Policy supports
comprehensive prevention programs that engage the community in changing attitudes and
behaviors through collaboration within systems of education, juvenile justice, mental health, and
public health (National Conference of State Legislature (NCSL), 2010). In addition, there may be
the opportunity moving forward to incorporated environmental design as indicated by a
stakeholder.
The second opportunity which exists is primary health care providers ability to prevent,
intervene, and create social support systems as well as an understanding of development of
depressive symptoms at different rates for youth (Carlos et. al, 2017; Gorman, Smith, & Tolan,
1998). The ability of the medical profession to find other ways to connect with patients is
imperative to combat medical conditions that are impacted by violence and ACEs. The
incorporation of multiple systems may allow for children and community members to feel that
there is truly no wrong avenue to enter in order to prevent and/or to heal from ACEs.
As the breaking down of barriers allows for the opportunity to address the social
determinants of health and researchers to work together to validate innovative practice (Patcher
et al., 2016). By starting with an informational campaign, it allows for us to assist the community
in building their own path for healing by providing input regarding how the project components
might be able to assist. As the project uses proven and data driven interdisciplinary approaches it
is believed by the project creators that this will assist community members in improving the lives
of children to grow to have healthy and productive lives (AASWSW, 2017). The project believes
that this might provide an innovative way to move forward towards being able to incorporate
data to make informed decisions within community settings.
How Innovation Links to Proposed Logic Model and Theory of Change
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The public health approach will allow for a population-based intervention that
encourages long term strategic plans involving surveillance, assessment, planning, training,
stigma reduction campaigns and policy advocacy for children under the age of 18 that are
exposed to violence by providing (Sood & Berkowitz, 2016; Malti & Averdijk, 2017; Slutkin,
2017; Purtle, 2017). The use of a multifaceted approach allows for the community providers to
exchange their view on the spectrum of violence from an individual witnessed and/or
experienced event to a strength-oriented perspective (Leitch, 2017). By allowing for multiple
systems to gain new skills towards creating a collaboration of healing that will result in better
health, reduction in violence and trauma symptomology as well as decrease stigma surrounding
the silence of ACEs. The introduction of knowledge through neuroscience allows for the
normalization of reactions of adversity events as it allows for an understanding that every human
is wired to respond to threat and fear in the same manner as the nervous system regulates the
physical, emotional and cognitive functioning in humans in the same way (Leitch, 2017;
Cozolino, 2002; van der Kolk, 2014).
Program Structure and Methodology
Description of Capstone Deliverable/Artifact
The capstone artifact involves multiple strategies focused on creating a healthier
community for children who experience violence. The first infographic involves an infographic
for community providers focused on brain science (Appendix B). The second infographic
involves a community-based campaign focused on helping community members learn about
ACEs and ways to help children heal. The infographic was created for the age group of 8-12.
The full program outline brochure allows for information regarding all areas of the program
using roadmaps that provide information surrounding the training and community groups. A
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training proposal for the second phase of the 3 minus T project. The training proposal will cover
the topics of: brain science, spectrum of violence, regulation of the brain and self, and learning to
focus on the direct experience through a practical skill development. The training proposal
details the objectives, content outline, presentation methods and handouts/materials that are
needed for the full 8-hour training (Appendix C). A training book was also developed to assist
with guidance through the training proposal. This was created to allow for attendees to be able to
follow and write down their thoughts and/or notes surrounding the training material (Appendix
D). The 3 minus T project will also have a full program brochure that will detail all parts of the
project (Appendix E).
Comparative Market Analysis
A current market analysis of the competitors reveals that organizations within the
Pasadena area are currently providing trauma informed care trainings and initiatives. The
following organizations were shown to be current training providers within the Pasadena and Los
Angeles area: Young and Healthy Organization is a 501(c) 3 which currently provides trauma
informed care trainings by bringing presenters well-known in the field to provide information
regarding trauma impacts. Trauma Informed LA is another non-profit organization of volunteers
with a mission “to foster resilient communities that promote healing and well-being through
collaboration, education, and community engagement” with the overall goal to have a trauma-
informed Los Angeles. Current mental health providers with in the area such as Pacific Clinics,
Hillsides, Five Acres, Hathaway Sycamores are providers of mental health services focused on
evidenced based practices and centered on a Medical and sliding fee scales for individuals that
meet medical necessity through impairments to their daily functioning. After-school programs
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such as the Boys and Girls Club, Jackie Robinson Center, and Villa Park Center provide sports
and leisure activity for children.
The program Community Partners in Care (CPIC) has also gotten acclaim for the
collaborative research conducted within the South Los Angeles and Hollywood -Metro LA area
towards reducing the burden of depression using a community-based approach. The national
program Veto Violence also provides online trauma informed care trainings. The Cure Model
provides a community centered approach using individuals within the community as interceptors
that are trained to combat violence. While all of these programs have brought innovation to the
field of trauma informed care there is no evidence that one trauma informed care approach is any
better than the next as the trainings can vary in ability depending on the violence type. On the
contrary, these programs can at times focus on one area/type of violence or mental health
symptomology.
The program, Be Strong Families, has a mission to “develop transformative
conversations that nurture the spirit of family, promote well-being, and prevent violence” (Be
Strong Families, 2019). This program provides trauma informed parent cafes and trainings
within the Pasadena and other cities and states across the United States. The Trauma Stewardship
training provides insight regarding how to provide stewardship to others while holding our own
trauma. The training is guided by the book Trauma Stewardship: An Everyday Guide to Caring
for Self While Caring for Others by Laura Van Dernoot Lipsky. This training is focused on
helping professionals and the impacts of trauma on those who they assist and witness. The
training looks at emotional triggers, energy leaderships, reflective practices for supervision, and
how to maximize positive energy using Be Strong Families personalized energy assessment
tools.
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The 3 minus T project is distinct from the other organizations as the Social Connections
Training and community groups are focused on practical skill development using a healing
centered engagement approach. Secondly, a focus group held for community members identified
that groups are not held in the community because there is lack of funding or they are removed if
there is lack of participation without finding out why individuals do not come. Many of the
programs within the city provide trainings and workshops for families within their office spaces
and community spaces. An interviewed substance use counselor expressed that there should be
an incorporation of all providers to find if there is potential for overlap and assistance or
outsourcing of sections of the intervention within faith-based agencies in the city. In conclusion,
the 3 minus T project is innovative as it takes the best pieces of the models that focus on helping
communities grow through trauma informed care and offers a comprehensive and preventative
approach that seeks to enhance communities versus being reactive to violence through ACEs.
For this reason, the 3 minus T project will change the future of how we view prevention and will
create hope that we can create healthier children, communities, and systems.
Project Implementation Methods
To improve the outcomes for those experiencing adverse childhood experiences, the 3
minus T project proposes to teach the City of Pasadena community a multifaceted approach to
healing, by implementing a community-wide practical skill building project using a public health
approach. In doing so, the project hopes children under the age of 18 living in the City of
Pasadena will benefit through safe and supportive communities with the skills to provide support
to children and individuals living with Adverse Childhood Experiences (ACEs). The project
proposes to be structured within the City of Pasadena Public Health Department. The proposed
project seeks to enhance the public health system by creating of an environmental health services
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department to respond to exposure of violence for children and youth as well as the community.
The redesign to the public health system would build operational capacity by creating better
health outcomes, reducing disparities, and be prepare the public health department to provide
support and address any form of violence. The organization would incorporate a divisional
structure as it would be structured within the City of Pasadena Public Health Department Social
and Mental Health Division.
The project structure would incorporate within the public health department a team in the
environmental health services department to address the exposure of violence to children and
adolescents. The project would be staffed by two full time employees which would include one
Licensed Clinical Social Worker (LCSW) and ONE (1) community environmental health worker
(EHW). The project will involve the role of a LCSW, EHW, and Bachelor’s and Master’s Level
Social Workers. The LCSW will have the role of oversight of the project, implementation
involving assessment of the community, outreach, training community members and providers as
well as provide clinical supervision and oversight to EHW and interns working on project. The
LCSW will provide management to the environmental health worker and MSW interns. The
LCSW would understand trauma informed care, healing centered engagement, and violence
exposure in the community. The LCSW would also have an easy-going managing style.
The EHW will canvas and identify areas of need after assessment, assist with promoting
community campaign through outreach, co-facilitate community focus groups and trainings to
community members and providers. The EHW will also canvas for community members that are
respected in the community that would be willing to assist and provide leadership on the
community sociotherapy groups. The environmental health worker would have positive
communication skills, enjoy working with the community, and be willing to work collaboratively
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with the LCSW, community stakeholders, and community members. Bachelor’s social work
interns and Master’s level Social Work clinical interns will assist with implementation of
community canvassing and administration of tools for methodology and other tasks as assigned
during course of internship.
The City of Pasadena will be the setting for this project which is the ninth largest city in
the County of Los Angeles. The activities will be conducted by the public health department in
multiple community locations in the north west and east parts of the City of Pasadena. The
northwest: Community Service Area 2 was chosen within the City of Pasadena as it involves the
highest socioeconomic need within the city such as: income, poverty, unemployment,
occupation, educational attainment, and linguistic barriers (Community Health Needs
Assessment of Greater Pasadena, 2016). In addition, the socioeconomic need in this area of the
city (Index value of 69.5) is found to be higher than Los Angeles County (Index value of 56.4)
(Community Health Needs Assessment of Greater Pasadena, 2016). There are 27, 153 family
households with children under the age of 18 (Healthy Pasadena, 2017). Secondly, this area of
the city has higher rates of children who live below the poverty level (29.8%) and higher rates of
children receiving SNAP (80.8%) (Community Health Needs Assessment of Greater Pasadena,
2016).
The participants for the project will be recruited within the northwest and northeast part
of the City of Pasadena. The second phase will involve all law enforcement officers and medical
providers working within the high violence areas of the Northwest: Community Service Area 2.
The participants for the third phase will involve residents within the northwest and east areas of
the City of Pasadena. The participants will be canvassed by LCSW, EHW, and interns through
flyers, office to office, and door to door, phone contact, and email by involving stakeholders
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(e.g.: police department, public health and hospital system administrators). In the first year of
operation, the project activities will involve 100 community providers (50 law enforcement and
50 medical providers). The third phase will involve 60 community members involving 30 adults
and 30 children.
The implementation framework phases of the intervention will involve phases in
planning, research, design, implementation, follow up, and data interpretation which will occur
over the course of one year. The project seeks to begin implementation as of January 1, 2020 –
December 31, 2020 (Table 2). The project seeks to use a mixed method research framework
approach by inquiring quantitative and qualitative data throughout the project to study the
impacts of the project interventions. First, the 3 minus T project will have to meet with the city
epidemiologist to work towards being able to successfully obtain a map regarding the areas of
high violence which is obtained using the Geographic Information Systems (GIS) Data. The GIS
data will have to be requested through the police department and can be obtained by the city of
Pasadena public health department. Secondly, data from various sources will be gathered such
as: Healthy Pasadena, California Violent Death Reporting System (CalVDRS), BRFSS, and
community assessment data. These data sources will be used to gain insight regarding the
impacts of violence. In addition, health indicators will also be used to see the overall health of
children within the city of Pasadena involving asthma, obesity, use of substances, and other high-
risk behavior as well as educational outcomes. Third, the project will look into stakeholders
within City of Pasadena Community Health Needs Assessment (CHNA) and Community Health
Improvement Plan (CHIP) which provide information regarding the strategic plan for the health
of Pasadena residents. The next step will involve educating the community through a campaign
providing education to the community regarding adverse childhood experiences and ways
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community members can help prevent the impact of ACEs on children under the age of 18. The
EHW and LCSW will canvas areas where community members and providers will have access to
the infographic information.
The second phase will involve community trainings to law enforcement, medical
providers and community members. The trainings will involve education on neurobiology,
spectrum of trauma and ACEs, brain regulation, and practice skill building interventions to be
used with children under the age of 18 and community members who are living with and/or have
been exposed to adverse childhood experiences. The EHW and LCSW will conduct outreach
within areas of high violence to provide community members with information regarding
enrollment for training and community providers within those areas. The training will be held at
the PPHD for 20 community providers and community members. The training will be provided
to 100 community providers and community members. The training will be an 8-hour training.
The training will involve the use of a PowerPoint and training book to guide the training
objectives. Training proposal contains a step by step roadmap through the training for
community members and community providers.
The third phase will involve community member trainings involving sociotherapy groups
and a practical skill building project. The community group will involve discussion topics such
as safety, trust, care, respect, new rules, and memory of emotions. The community group will be
open to anyone over the age of 18. The children’s group will involve discussion topics such as
healthy growth and development, guilt and acceptance of imperfections, responsibility,
teamwork, risks of choices and chance to improve their lives, self-identification, gratefulness,
and new experiences involving fun events throughout group sessions. The children’s group will
start with children between the ages of seven to eleven. The community group and children’s
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group will be implemented within the community within the north west and east parts of the City
of Pasadena.
The organization would know that it has been successful when there has been a decrease
in the direct and indirect witnessing and experience of violence through forms of adverse
childhood experiences within the Pasadena community that is experiencing violence. In addition,
a decline in the levels of traumatic symptomology after violence exposure. The objective would
be to involve professional and community providers as well as community members. In addition,
it would provide every child and youth with a population-based approach before violence
exposure or within the first three months after exposure to violence and provide linkage to
individual services as needed/required.
Financial Plans and Staging
The implementation of finance strategies for this project will involve showing a direct
reduction in costs to violence exposure of children and community members (Powell, 2012). The
project proposes to use a collaborative to analyze the ongoing need for further training to
community providers, need for accommodations or changes to curriculum and project goals and
objectives. The collaborative will enact a steering committee in order to discuss funding sources
looking towards health and social welfare funding and benefits and costs across multiple funding
sectors (Steverman & Shern, 2017). The quality management strategies of implementation for
this project would involve using the project collaborative to verify a plan to enlist the assistance
of community members that are focused on moving the project forward in a successful manner
(Pachter et al., 2016). The collaborative would also need to have a strong organizational and
community-based organization support through leaderships. The Public Health department
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would need to review how to continue to partner with organizations that may provide
administrative and organizational aspects (Pachter et al., 2016).
The organization funding would seek sources of revenue via grants from Calwellness for
$150,000 for a period of 3 years accounting for $50,000 each year. The Substance Abuse Mental
Health Services Administration ALSO HAS FUNDING AVAILABLE specific to research on
new emerging treatment modalities with the amount of the grant being unavailable due to not
currently being released until 2018(??). The Family and Youth Services Bureau ISSUES grants
from 400,000 to 5.5 million. The organization will also seek out fee for services by the
Department of Mental Health and apply for innovation AND/OR prevention grants. The PPHD
epidemiologist also discussed potential to obtain a small micro grant to implement the 3 minus T
project training. The organization would also seek in-kind and private donations to support the
project through cash and volunteers. The organization will implement a project-based budget
format that will document revenue and expenses for organization.
The organization will have expenses in the form of staffing and plan costs for the
environmental health worker at a rate of $40,000 and Licensed Clinical Social Worker $85,000.
The salary rate found in the line item budget is an average rate accounting educational level. The
organization would also provide fringe benefits (@30 percent) by providing medical insurance,
retirement, and other state/local benefits in the form of payment for unemployment
compensation, workers compensation, and SSI. The organization would also have other spending
plans and costs involving rent/mortgage to implement organization and project services. The
organization would also provide computers, equipment in the form of printer, copier, and
scanner. The workshops will provide food during trainings, workshops, and termination of
workshops. There will also be other expenses in the form of phone lines, travel to and from
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locations, and utilities in the form of electricity. The organization will require malpractice
insurance. There will also be miscellaneous funds for incidentals not accounted in the fiscal year
budget. In addition, some expenses may vary due to time of year, cost at time of purchase, as
well as travel depending on frequency of travel within the city.
The revenue versus the cost is analysis provides the following for the organization. As
the organization would be a start-up as reflected in the line item budget there would be a small
surplus of $1,000. In addition, there is also a potential that if the state, federal, and/or local grants
were to have the surplus that the funding would have to be returned to the grant funder. There is
also another option for the surplus which is to be used for the operational costs not covered by
funding sources. The cost would have challenges if employees were to leave the organization
within the first year of implementation. The project does have a potential to grow and involve
community allies and assist with the needs of the community. The stakeholders of families,
community members, and community providers experiences as part of the project would also
need to be involved in sharing their community experiences to providers to assist with not losing
funding from grant funders to provide services. This has been identified as a possibility within
organizations that are not able to manage community needs and have a negative association with
that organization.
The organization reward system would involve compensation in the form of a salary and
fringe benefits (@30%) such as medical and dental insurance. The other rewards systems would
be to identify the needs and wants of our organization surrounding learning, teaching, and
sharing of organization mission. The organization will create a vision board to describe and
reflect on positive impacts within the community as well as challenges in doing the work. Team
building activities would be created to assist with creating a stronger department within the
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department. The department will use a trauma-based approach to prevent compassion fatigue for
challenge and intense community intervention phases and workshops. The organization will
encourage collaboration with other public health departments, gain new skills, provide insight to
other departments, and collaborate with stakeholders. As the organization grows the project
would require to create a career ladder chart to provide ascension to other organization positions.
The feasibility of our proposed public health trauma informed care community intervention will
provide a multifaceted approach to adverse childhood events by incorporating providers to
address ways to prevent and diminish potential victimization by community providers. For the
line item budget and staging please see Appendix G & H.
Project Impact Assessment Methods
The 3 minus T project will evaluate the activities of the program by using multiple
measurement tools. The first phase will involve analysis of qualitative data to be able to provide
information in a reporting system. The Self-Reporting Questionnaire (SRQ-20) will be used to
provide guidance regarding trauma impacts to mental health as it allows for easy “acquired
mental health symptom data and may be a vital tool to advocate for increased mental health
resources and common mental disorder screening” (Van der Westhuizen et al., 2015). The
benefit to the use of the SRQ-20 is that nonprofessional health workers may administer the
questionnaire to identify patients in need of further mental health resources (Van der Westhuizen
et al., 2015).
The second phase training component will be evaluating multiple outputs. The first
output will involve demographic data regarding the participants for the training. The second
output will be the number of registered training participant to those that attended the training.
The third output will involve a pre and post knowledge test, 35 item Attitudes Related to Trauma
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Informed Care (Artic) Scale, and the Stanford Professional Fulfillment Index. These
measurement tools were chosen as they provide information on non-psychometrically tested and
psychometrically tested tools for social science programs. The knowledge test is not a
psychometrically tested tool, but it will be used to obtain information regarding knowledge
regarding ACEs, symptoms and behaviors, and identification of practical skills developed in
training. The 35 item Attitudes Related to Trauma-Informed Care (ARTIC) Scale has five core
subscales and two supplementary subscales (Trauma Stress Institute, 2018). The scale is one of
the first psychometrically valid measure of trauma informed care (TIC), generated by content
experts within a community participatory research approach. This measurement tool contains an
excellent internal consistency (α = .91) and subscale alphas ranges from respectable to very
good, and test-retest reliabilities were strong with in all three versions (Trauma Stress Institute,
2018 ). The Stanford Fulfillment Index is a 16-item instrument that will be used to measure
change in sensitivity and wellbeing of providers through assessment of professional fulfillment
and burnout (Trockel et al., 2018). This measurement tool will be used as it measures
professional fulfillment, work exhaustion, and interpersonal disengagement. The instrument has
a test-retest reliability estimate of 0.82 for professional fulfillment (α = 0.91), 0.80 for work
exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall
burnout (α = 0.92) (Trockel et al., 2018). The instrument provides quality performance
characteristics surrounding sensitiviety to change and novel contributions by assessing
professional fulfilment and burnout (Trockel et al., 2018).
The third phase will involve multiple outputs focused on intervention of sociotherapy
groups for children and adults in the community. The first output will involve demographic data
regarding the participants for the community groups. The second output will be the number of
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eligible community members for the intervention, number of areas that are willing to implement
the community groups, and attendance rates and total hours for community members. The SRQ-
20 will also be used to identify a baseline for community members and children at beginning,
end, and 6 months follow up.
For the purpose of this project, the RE-AIM model was chosen as it is a framework
within the public health system which has been used to evaluate effectiveness and
implementation outcomes which necessitates the use of both qualitative and quantitative methods
(Holtrop, Rabin, & Glasgow, 2017). The model uses the following dimensions: reach,
effectiveness, adoption, implementation and maintenance (Glasgow, Vogt, & Boles, 1999). The
RE-AIM framework is an efficient implementation framework for health interventions as it
allows for creation of a plan, evaluation, health policy impact, assessment of literature and
computation of metrics to estimate the intervention impact (Lee et al., 2017). This framework
also provides insight that broader dissemination is necessary in order to address population
health by addressing questions relevant to the body of research (Eakin et al., 2007). For the
purpose of this project, the Reach in the RE-AIM process involves reaching out to the children,
community providers, and community members most impacted by violence in the form of ACEs.
The project will use the following steps to ensure that the target population is reached.
The effectiveness of the project will be analyzed throughout multiple phases. In the first
phase being able to document the number of community members who receive the information.
The third phase effects will be assessed through pretest and posttest and a 6 month follow up
involving a 35 item Attitudes Related to Trauma-Informed Care (ARTIC) Scale to inquire
regarding their attitudes towards trauma informed care. The ARTIC scale has five core subscales
and two supplementary subscales (Trauma Stress Institute, 2018). This scale is one of the first
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psychometrically valid measure of trauma informed care (TIC). The Stanford Professional
Fulfillment Index 16 item instrument to measures changes in sensitivity and wellbeing of
providers through assessment of professional fulfillment and burnout (Trockel et al., 2018). The
extent of change will be apparent in the knowledge, attitudes, development of practical skills
among community providers in trauma informed care. The fourth phase will review effects by
the number of community members that are attend group sessions and complete group sessions,
as well as pre and post test scores on developed community group and children’s group self-
administered test on adverse childhood experiences.
The adoption of the implementation plan will involve the absolute number, proportion,
and representativeness of setting and participants that are willing to start the project (REAIM,
2018). By providing the community a space to provide input on community education material
we hope to obtain community buy-in and adoption of strategies through campaign. In the
training phase, the use of a focus group after 6-month follow up will also allow for community
providers to share how the intervention knowledge has been transferred to real-world settings.
The use of evidenced based measurement tools will also assist in creating a knowledge base
towards an effective trauma informed care model. The community and children’s groups will
allow for community members to have a input regarding which community changes will help
their neighborhoods throughout the course of the intervention. After adoption in the areas of
highest violence, it will allow for adopters to discuss how to branch out to other areas of the city
that are identified as moderate and low violence areas. This slow progress will allow for the
adoption of the intervention city wide with active input and modification for adaptation for other
areas of the city.
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The implementation phase involves the consistency, costs, and adaptations that are made
during delivery (REAIM website, 2018). For the purpose of our study, the delivery of the
intervention will be assessed regarding the fidelity of the model, time, and total cost from
beginning to end of the intervention based on the model. The study will involve multiple baseline
assessments throughout the multiple phases. The third and fourth phases will involve pre-test and
posttest through the use of measurement tools throughout intervention and a 6 month follow up
and focus group to allow to discuss with participants challenges to fidelity. Treatment providers
will also fill out fidelity tools to ensure that the training has been implemented in to the model
and participants are receiving quality training.
The maintenance segment assesses the long-term effects in individuals and setting over
time through discontinuation, modification, and sustainability of the project (REAIM website,
2018). For the purpose of this project, we know that using a public health approach through
evidenced based approaches has created successful responses to health conditions around the
globe and have enhanced the populations life expectancy by more than 30 years (CDC, 2017;
Brownson, Fielding, & Maylahn, 2009). In addition, this allows for modifications as needed to
interventions that promote health and well- being. The 3 minus T would work towards creating a
collaborative throughout the second phase when providing campaign on adversity within the
community. This would allow for a collaborative organization within the public health
department who would engage diverse and culturally competent community members,
community stakeholders, and create a space for active discussion on objectives and readiness of
neighborhoods to have intervention implemented to community providers. The collaborative
would also take into consideration risk and protective factors, resources, readiness, suitable
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interventions, and timeframes for change in community culture (Center for Disease Control,
2017).
The 3 minus T project will have three phases of activities. The first phase will involve
incorporating the disease investigations, surveillance, and violence data within the City of
Pasadena to be able to obtain the areas within the city where children experience higher levels of
violence. An epidemic model public health approach would be used to assess and identify
individuals in the community areas at higher risk level of violence exposure. As the public health
approach views, risk level it will allow for the implementation team to be able to identify would
be assigned based on susceptible, infected, and removed categories after community assessment
for the community. The assignment of risk level would allow for target populations to be
identified within the city. The assignment of risk level within the city will use a care first level
identification to prevent stigmatizing and labeling communities through using a Rose High Care
which involves high violence areas, Pink Medium Care which involves susceptible areas which
have some violence, and Yellow Low Care which involve little to no violence. The community
was also be informed of the levels of care in order to have they provide input regarding if there is
any other names they would like for the identified areas to be named.
The overall aims of the program are to evaluate the impact of creating a community
conscious of adverse childhood experiences and violence impacts. Secondly, to create a healthy
development for children and families in the community, and to provide practical skills building
focused on healing centered engagement surrounding adverse childhood experiences.
Stakeholder Engagement Plan
The 3 minus T project plan to engage Stakeholders sets to ensure community feedback at
all levels. The first step was to create an engagement plan to obtain community feedback by
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conducting semi-structured key informant interviews that would be able to identify and confirm
community perspectives on violence and ACEs. This would involve identifying key community
resources involving members in the community providing service (law enforcement, medical
providers, and firefighters), residents (community members living in areas of high violence),
caregivers of children (grandparents, foster parents, parents, and adults caring for children) and
children ages 7-12 years of age. Community members and providers interviewed will also be
provided with infographic samples to provide input regarding if infographics require other
images and/or if there is information that might be beneficial and/or missing. The second step
would involve holding a large community stakeholder meeting for two-hour periods to obtain
community feedback and listening sessions regarding preliminary data on violence and ACEs in
the community. The community stakeholders would be able to provide their perspectives
regarding the gaps in data, quality of data, and sources of data in the community to create a
unified plan towards ways to improve the community. This process would be done at an
alternative time with professional organizations and city government to obtain input towards
engagement of these organizations in the project. The types of organizations that will be sought
will be Faith-Based Organizations, Maternal Care Management Programs, Youth Advocacy non-
profits, Governmental Child Services Agencies, Behavioral and Mental Healthcare Agencies,
Pasadena Community Advocate, Local School Districts (Staff and parents), Hospitals and
Federal Qualified Health Care centers and/or Private Medical Offices and Youth and Family
Services Non-profit. The participants in these stakeholder meetings would then be provided with
information regarding the potential plan for implementation of a multi-systematic approach to
community violence to obtain input regarding the potential success of the 3 minus T project.
These meetings would use open ended feedback to the problem of violence and ACEs. The
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project will ensure that the organizer will have ample time for dialogue with participants and ask
for participants to share their solutions to the problem
The stakeholders identified in these meetings would be asked to join the 3 minus T
Advisory Group by agreeing to attend three meetings of 6 meetings a year to be held within their
community settings to continue to obtain feedback regarding the progress of the project and
improvements witnessed within the community. Collaborative members will be encouraged to
provide feedback regarding the 3 minus T project and the delivery systems methods to access the
potential for the 3 minus T implementation within their communities. These stakeholders will
also be asked to identify champions within their community that would benefit from the 3 minus
T training. The advisory group will work towards obtaining a diverse group for internal and
external experts. The advisory group organizers will have an opportunity to opinions, have
expert speakers on topics involving violence and ACEs, and identify areas most useful towards
the gaps in data.
Communication Strategies and Products
The 3 minus T program will create two infographics one to be used with community
providers when conducting community engagement meetings. The first will be an infographic
focused on the science of ACEs. This infographic will provide more information regarding the
data behind adverse childhood experience and the brain science behind it. As this infographic is
more technical, the project will ask for community input regarding changes necessary for
implementation city-wide. The second infographic will be focused on helping community
members identify ACEs and ways to help children 8 - 12 years of age prevent and/or minimize
the impacts of ACEs. The infographic will be titled, “How to help the brain heal for children
living with Adverse Childhood Experiences (ACEs) will be used to provide the community with
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general information on ACEs and how every community member can help children. These
infographics will provide awareness surrounding ACEs and their lifetime impacts. The second
communication strategy will involve the use of a program media to allow for community input to
the different phases of the project and will outline the direct implementation of the program
within the city. The infographics will also be created into animated gif’s that are read to ensure
that those residents who have challenges with the information will also be able to have access to
the material. The third communication strategy will be the training proposal and training book
that will be provided to stakeholders to provide input surrounding the viability of the training.
The 3 minus T program believes that by using multiple forms of communication strategies the
program might be able to create further support for the use of prevention strategies within the
public health and community arenas. By providing information to community stakeholders in
multiple formats it allows for the idea of a healing centered engagement approach to have the
potential to reach various audiences.
Ethical Considerations
The ethical limitations involve the risk of completing the interviews and causing distress to
community members by asking questions regarding the sensitive topic of adverse childhood
experiences and the measurement tool (Self-Reporting Questionnaire (SRQ-20)). The second
limitation involves mandated reporting as City of Pasadena employees are mandated to report
safety concerns involving suicidal, homicidal, and abuse of children and adults with disabilities
and/or over the age of 65. This creates a limitation in the ability of individuals to be able to
provide open and honest answers to questions and measurement tool SRQ-20. The next
limitation involves the interviewer to be able to provide a safe and open space for community
members to feel safe in sharing their previous trauma and current symptoms and behaviors. The
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potential method to mitigate these limitations would involve training for staff (e.g.: LCSW and
EHW) regarding skills for interview, processing community members current concerns and
needs during and after interview, as well as provide information regarding providers in the case
of requiring further support. A second strategy will be to have clinical supervision to discuss
safety concerns with community members and problem solve on a case by case basis regarding
appropriate safety steps to take. In addition, to providing information to community participants
regarding mandated reporting laws and limitations of the interviewer.
Conclusions, Actions, and Implications
Summary of Project Plans
The 3 minus T project is an innovative project that will create a multi-systematic
population-based approach within the community focused on the preventing and/or healing the
impacts of ACEs. The 3 minus T project is an innovative approach as it is the first community-
based approach that uses a neuroscience within a community setting. The project looks towards
using multiple strengths from various approaches used with prevention and intervention model.
The project will use three phases that will incorporate a disease investigation, surveillance and
outbreak implementation using a public health framework. The second phase will involve a
Creating Social Connections training to focused on providing community providers and
community members an 8-hour training focused on neurobiology, spectrum of emotional and
psychological trauma, and practical skill development. The last phase involves sociotherapy
community groups that will provide a space for community members and children to gain skills
and knowledge surrounding healing and moving forward.
The project will engage various stakeholders within the city by individual interviews,
community canvasing, and engagement through dispersal of infographic information to
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community providers and community members. The communication strategy will involve using
these mechanisms of infographics and animations and brochures in order to get the community
involved in creating change for children under that age of 18. The aims of the project use
quantitative and qualitative data to determine whether a public health approach using a
population-based intervention can address adverse childhood experiences through prevention
focused trainings on practical skill development and community groups within neighborhoods
impacted at a higher rate to experiences of violence. The use of a multi-systematic population-
based approach Social Connections training is innovative as it seeks to prevent ACEs and focus
on practical skill development for providers and community members. The use of neuroscience
and healing centered engagement process allows community members to provide the next step
after trauma informed care as it focuses on creating a tool to be used to prevent ACEs and
violence. The artifacts have also been prepared and are ready for implementation within the
community.
Current Practice Context for Project Conclusions
In conclusion, the problem of violence through adverse childhood experiences is a
multifaceted problem for children under the age of 18 which has been documented by
interdisciplinary fields as a preventable event in a child’s life. As current systems only address
the problem from a siloed perspective there appears to be a need for comprehensive systems to
address the problem of violence in childhood. The restrictions for many organizations lie in the
approach to violence. Mental health systems have taken an individualized and family approach to
violence exposure restricting services only to those experiencing severe mental health and
behavioral symptoms. The criminal justice systems have long addressed violence from a stand
point of restoring order and justice and fail to prevent violence or address mental health
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concerns. The public health system may provide the largest potential to implement a population-
based violence prevention plan may be the public health system (Purtle, 2017). The program
suggested for implementation in this paper seeks to look for an opportunity towards an
innovative population-based approach towards violence prevention in communities most
impacted by violence. The key is to be able to implement the interventions as a prevention tactic
to prevent death, disability, and injury for children under that age of 18.
Building healthy children involves every individual in a community. If we are to improve
the lifetime impacts of children and communities exposed to violence we must find creative and
innovative ways to heal violence exposure. In addition, immediate response to violent events is
needed to foster collaboration and empowerment in communities who experience multiple
violent exposures. When communities work together and leverage the resources with guided
support and not just viewing our community members as a funding source that is when
community will become strong and violence may cease to exist. Lastly, when communities build
and collaborate together to heal through innovative and creative ways there is a journey towards
empowerment, strength, and reduced violence.
Project Implications for Practice and Further Action
The project potential is limitless as the 3 minus T project is an innovation that believes
that healing trauma is a right not an option for communities who are ready to heal and thrive
after exposure of adverse childhood events to improve their emotional and physical health. The
goal in implementing the three phases is to create more data and information towards healing
centered engagement model that incorporate social science and public health. The 3 minus T
project believes that when the interventions are successful we will be able to provide information
as to how to prevent ACEs through a community-based approach and will be able to implement
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city-wide then within LA County and then statewide. The second action is that by healing
exposure to violence and ACEs there is a benefit in reducing the negative impacts to health, risky
behavior, substance use, and moves community members towards healthy and successful
individuals. The next action step would be to prove a healing engagement approach would be
beneficial to prevent ACEs as it creates a more open approach for healing and also to be open to
discussing previous violence exposure and ACEs.
Project Limitations
The complications for the program would be to be able to engage a city public health
department and city to invest in a program that has not been proved to be effective. In addition,
the program would have to be approved by the City of Pasadena in order to be able to be
implemented in coordination with the public health department. The second complication would
come from multiple organizations viewing the problem of violence through a narrow lens
focused on creating silos rather than creating a comprehensive system. Community
Organizations in the private and public sectors have apprehension to incorporate multiple
organizations due to fear of losing funding streams. The problem of collaboration within
agencies is at times challenging as some agencies feel that they address the area of community
violence in a more effective manner than other organizations. Yet, the organizations within a
community that would provide a multifaceted approach, such as the Public Health System,
reports limited knowledge regarding approaches towards community violence and multifaceted
tools needed to address this problem.
The limitations for the project may involve a small size of participants due to low
community member and provider participation. As the project focuses on areas within the City of
Pasadena that experience high violence which may pose a challenge in being able to obtain a
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large number of participants that will be willing to participate. The second limitation involves the
use of measurement tools as the measurement tools chosen for this project are self-reporting
tools. As the measurement tools are self-reporting this might create a limitation in how the
project participants answer. The third limitation involves changing the mindsets within
community providers and community members as current mindsets involve providing treatment
versus prevention. This will require using materials to engage stakeholders and community
members in the importance of prevention and the overall benefits to the community. The project
team will mitigate these limitations by using the stakeholder and communication plans to provide
information to the community members and community providers. In addition, the use of
continued input from the community members and community providers will also assist in
providing information to other areas of the city regarding the benefit of the project. Funding is
also a limitation as prevention interventions are not readily reimbursed by federal and/or state
funding sources. The 3 minus T project will have to seek alternate funding sources and
implement parts of the project that might be able to generate revenue such as the training
components before the community group interventions can be implemented. Lastly,
collaboration might be a limitation as organizations within the City of Pasadena may have
current policies that does not all them to work towards prevention strategies for funding
purposes.

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Creator Carrasco, Nereida (author)

Core Title The 3 minus T spproach: building meaningful community connections by designing neighborhoods conscious of the effects of adversity focused on the healthy development of all children

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 06/04/2019

Defense Date 05/10/2019

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Advisor Karim, Nadim Nassirali (committee chair), Enrile, Annalisa V. (committee member), Southard, Marvin (committee member)

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