ACEs Too High

Time 2020-07-26 03:04:07

Web Name: ACEs Too High

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In late May, Betsy Andersen’s 7-year-old son, Ezra, had a serious meltdown. He and his six-year-old sister Abby had been enjoying an online Zoom interaction with “Miss Eileen,” “Miss Savannah,” a couple of their colleagues, and a puppet.Betsy Andersen“I could see him trailing off and then he started crying,” says Andersen, who lives in Mundelein, Illinois. But before she swooped in, she heard Miss Eileen talking to him: “She was saying ‘Hey, I see you’re having some big emotions.” Speaking through the puppet, Miss Eileen then led Ezra through some breathing exercises that helped him calm down and focus.Andersen, like parents all over the country during the pandemic, has been looking for ways to fill the void left for her son and his sister while they’re shuttered inside, isolated and dealing with all kinds of feelings they don’t understand.“I’m not taking my kids to the store or anywhere. They’re really lonely,” says Andersen, who is trying to keep them active and engaged while doing contract work as a graphic designer. The lack of a fixed schedule is also tough for her son, who gets additional help online for various emotional and developmental issues, though not as much as he received in person at school.In fact, the facilitators on the Zoom call are particularly adept at working with children and families around times of profound traumatic stress. They’re trained in a specialty known as Child Life, which works with families on the grief, fear, and anxiety that children often experience while receiving medical care for serious illnesses or injuries. While Child Life specialists typically work in hospitals, some are pivoting into other areas and are now applying their skills to the fallout from the pandemic. Some have also been coming up with suggestions for ways to help children process feelings about frightful events captured in the news, such as the killing of George Floyd.Among those who have branched out is Miss Eileen, aka Eileen Esposito, a Child Life specialist in Tampa, Florida, who helped develop the group sessions that Andersen’s children attended, called Coping through Connection. Esposito and her colleagues are part of an organization that had already stepped outside traditional medical settings, the Child Life Disaster Relieforganization (CLDR), which operates virtually and includes 18 contract Child life specialists around the country.The group was formed in 2016 to help mitigate trauma in children who have experienced disasters and crises. It also partners with organizations who are deployed to disasters, such as Children’s Disaster Services. It worked with children who lived through the devastating massacre at a country-and-western concert in Las Vegas in 2017, and with children and families who survived Hurricane Dorian in the Bahamas in 2019 and Hurricane Maria in Puerto Rico in 2017.Much of their work involves child-led play, says Katie Nees, one of CLDR’s founders who lives in Cincinnati, Ohio. She recalls an experience working with children in a homeless shelter in Moore, Oklahoma, in 2013, which predates CLDR, but is instructive. Using cardboard boxes, magic markers, crayons and tape, the kids in Oklahoma built their own houses and networked with each other.Katie Nees“They’d say things like, ‘You’re my neighbor, you’re my neighbor, if anything happens, we’ll stick together,’” says Nees. “After a couple days, they had a moment of high energy and ran around making lots of noise. They ended up ripping the houses to shreds,” she says, adding that the scene mirrored the reality of what was visible just outside.After the demolition, the kids asked for time to sit and be calm, and Nees brought them snacks and drinks.“We all sat together and [absorbed this feeling] of safety of the moment,” she recalls. “Watching them play out that entire situation the way they did it as a collaborative effort and then at the end just making time for safety and calm, was incredible. I’ve never seen anything like it.” (Here are some resources from CLDR.)A turning point for Nees, who has worked in hospitals as a Child Life specialist since 2010, was when she came to understand how clearly the work of Child Life specialists was grounded in ACEs science.In 2015, she read the groundbreaking book by science journalist Donna Jackson Nakazawa, Childhood Disrupted, which shows the links between childhood trauma and adult illness and offers ideas on how to facilitate healing. The book introduced Nees to the landmark CDC/Kaiser Permanente Adverse Childhood Experiences Study (ACE Study), which linked adverse childhood experiences (ACEs) to adult onset of chronic disease, mental illness, violence and being a victim of violence in more than 17,000 adults.The ACE Study examined 10 types of childhood traumas, including living with an alcoholic or depressed parent or experiencing abuse or neglect. The study participants were mostly white, middle- and upper-middle class, college-educated, and had jobs and great health care. The study found that ACEs are common—most people have at least one. People who have four or more different types of ACEs—about 12 percent of the population—have a 1200 percent higher risk of attempting suicide and a 700 percent higher risk of becoming an alcoholic, compared with people who have no ACEs. Many other types of ACEs—including racism, bullying, a father being abused, and community violence—have been added to subsequent ACE surveys. (ACEs Science 101; Got Your ACE/Resilience Score?)The epidemiology of childhood adversity—which produce ACE surveys—are one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, how toxic stress is passed on from generation to generation, and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.Nees says learning about the ACE Study changed everything for her.“It was the first time I had found something that really quantified the importance of mitigating stress and trauma in childhood,” she says. ACEs science also reinforced for her the relevance in Child Life work of creating safe places for children, where they can express their emotions to supportive adults, who can help them process those feelings and build resilience.To get a sense of specific needs that were bubbling up in communities around the pandemic, Nees, Esposito and their colleagues conducted impromptu focus groups among parents and educators in April.Eileen Esposito“We saw that the biggest glaring need was the need for connection,” says Esposito. That realization led to Child Life’s online Coping through Connection series, which has served about 75 children, once a week, for eight weeks.As was the case for the kids in Oklahoma, the children participating in the online groups were also allowed to lead.“We’re not teachers who are going to stand up and provide a lesson. We’re supportive adults who are there to see what comes up with the children themselves and let them lead the conversations,” Esposito says.In Andersen’s group, for example, she says they asked the children what activities theywanted to do.“What do you want to do after the opening song? Do you want to play charades in the middle or at the end?” they asked the kids. Then they created a visual schedule that the children could refer to. And when children are visibly upset, the adults encourage them to share their feelings, as they did with Andersen’s son, Ezra.Esposito gives an example of a technique to help a child cope and build resilience: naming and locating a magic power.“One of the kids assigned a plant with the superpower to make everybody happy with a smile. It was so sweet,” she explains. “What he was communicating was that he sees and senses fear around him. He knows that people are not happy. He’s not happy. He doesn’t get to go to school. Mommy’s all of a sudden home all the time, and she’s stressed out, working from home and yelling more.”Because some of her colleagues are seeing children in their own communities who’ve expressed fear connected to the killing of George Floyd, Esposito says that they want to be prepared should it come up in an online group.A common response among young kids when they see disturbing news on TV is to personalize it, Esposito explains.“It could be ‘George Floyd looks like my dad. Is this going to happen to my dad or to me and my family?’” As Esposito sees it, it’s an opportunity for a Child Life specialist to allow the child to express their fear, and then use a developmentally-appropriate intervention that the child chooses. For example, she says, “They can draw their safe place or their families. And to further empower the child in feeling safe, brave and strong, have them identify the strong members of their family.”While CLDR is now looking to revamp their online offerings, which have continued through July, Child Life specialists elsewhere are being tapped to respond to in-person needs around the pandemic. Wenonah Elms, the disability and mental health coordinator for the City of Oakland’s Head Start program, is one person who reached out to local Child Life specialist Jonathan Iris-Wilbanks with concerns about what reopening would look like.“How do we ensure the mental health and social wellbeing of the teachers and the children in an environment where there is increased anxiety and [so many new] health and safety protocols?” asks Elms. She also ticked off a number of other concerns, like how to deal with children who are constantly wiping their nose, sharing bodily fluids, and touching things.Iris-Wilbanks, who is the director of the graduate Child Life program at Mills College in Oakland, California, and a Child Life specialist at Stanford Children’s Health/Lucille Packard Children’s Hospital in Palo Alto, California, describes some of the protocols that were used in hospitals to minimize the spread of infections while children were involved in play, which he shared with Elms.Jonathan Iris-Wilbanks“If we re going to use playdough,” he says, “we ll just make a really big batch of it, and we ll put out half for the morning and then use the rest in the afternoon.”Iris-Wilbanks also gave Elms some innovative ideas to consider: “Think about doing a sensory project that incorporates community” he suggests. “If all of our focus is on cleaning, and hand hygiene, why not do a community project where kids are sweeping the outdoor play space? Or have bins of soapy water so that kids can wash the truck together?”All of the preventive measures for safe play harken back to enabling children to feel connected in the midst of the pandemic. During an exercise developed by Coping through Connections to create a “coping wheel,” Andersen’s son, Ezra, who sometimes struggles to express himself verbally, was busy drawing.Sister and brother Abby and Ezra drawing their coping wheels“I looked over, and he had drawn five or six people interacting on a computer screen. He wouldn’t have been able to say that one of his coping skills was talking with his friends in this group on a computer screen, but he drew it,” says Andersen. “It was such a confirmation.”About two years ago, a team from LifeLong Medical Clinicsjumped at the opportunity to integrate practices based on adverse childhood experiences when it joined a two-year learning collaborative known as theResilient Beginnings Collaborative(RBC). RBC began in 2018 and includes seven safety-net organizations in the San Francisco Bay Area. (Here’s alink to a reportabout the RBC.)To join the RBC, LifeLong Clinics — which has14primary care clinics in Alameda, Contra Costa and Marin Counties — and the other collaborative teams had to agree to introduce all staff members to the science of childhood adversity and trauma-informed practices. LifeLong went full steam ahead with a 2.5-hour introductory training for more than 100 employees who work at its clinics that serve pediatric patients.Trauma Transformed, a program of the East Bay Agency for Children in Oakland, CA, did the training in October and November 2018.LifeLong Clinics’ decision to move forward on integrating ACEs science and trauma-informed practices into its clinics is important particularly in California where a state policy has made childhood adversity a front and center issue. On Jan. 1, 2020, as an incentive to doctors who serve Californians in the state’s Medicaid program, the state began offering supplemental payments of $29 to doctors for screening the estimated12 million pediatric and adult patients for adverse childhood experiences (ACEs).ACEs comes from the groundbreakingAdverse Childhood Experience Study (ACE Study), first published in 1998 and comprising more than 70 research papers published over the following 15 years. The research is based on a survey of more than 17,000 adults and was led by Drs. Robert Anda and Vincent Felitti. The study linked 10 types of childhood adversity — such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive — to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Manyother types of ACEs— including racism, bullying, a father being abused, and community violence — have been added to subsequent ACE surveys. (ACEs Science 101;Got Your ACE/Resilience Score?)The ACE surveys — the epidemiology of childhood adversity — is one of five parts of ACEs science, which also includes how toxic stress from ACEs affects children’s brains, the short- and long-term health effects of toxic stress, the epigenetics of toxic stress (how it’s passed on from generation to generation), and research on resilience, which includes how individuals, organizations, systems and communities can integrate ACEs science to solve our most intractable problems.After it trained employees in 2018, brainstorming around workflow was provided for staff at the LifeLong Howard Daniel Health Center in Oakland, CA, in February 2019, where LifeLong plans to pilot ACEs screening in newborns to five-year-olds, said Dr. Omoniyi Omotoso, the pediatric lead at LifeLong Clinics, who led the brainstorming about workflow and additional training.Four months into that training, in June, Omotoso showed staff the ACEs questionnaire and asked them how they thought patients would feel about it.And that’s when Omotoso realized that they had to put on the brakes. “A lot of the staff were uncomfortable because they themselves had similar instances that they personally were triggered by as they read the [ACE] questions themselves,” said Omotoso, who splits his clinical time between LifeLong Howard Daniel Health Center and LifeLong William Jenkins Health Center. He said that LifeLong will be using the de-identified PEARLS ACE screener for its pediatric population, which asks those surveyed to write on the form the number of ACEs that apply to them. (Here’s a link to ACEs Aware, where you’ll find out more information about PEARLS, the only pediatric ACEs screener for which California providers can be reimbursed.)When you’re working with people who ve had a lot of childhood and adult adversity, it’s hard for you to believe that anyone else can have a bad day, says Laura van Dernoot Lipsky. “Your neighbor or your best friend says: ‘I’ve had a bad day.’ And you think, ‘Oh, I’m sorry you had a bad day; were you sex trafficked today? No, you were not! ”Van Dernoot Lipsky, the author ofTrauma Stewardship: An Everyday Guide to Caring for Yourself While Caring for Others, was driving home one of several points of how working in a job that serves severely traumatized people can harm people who help them, too.Dr. Ken Epstein has been in the social services sector for nearly four decades and has witnessed firsthand the long-term effects of trauma. As both the son and father of fellow social workers, the work runs in his blood. He has been frontline staff at a residential facility for youth with severe mental and emotional challenges, a therapist, a family and couples therapy professor and director of the Child, Youth and Family System of Care for the City of San Francisco’s Department of Public Health. Now, he’s helping Bay Area health clinics screen for and address childhood trauma through theResilient Beginnings Collaborative(RBC), led byCenter for Care Innovations(CCI) and made possible by Genentech.Trauma is pervasive. Studies show that one in seven children in California experience trauma by age five (Children Now, 2018), and research links adverse childhood experiences (ACEs) – incidences of abuse or neglect, household dysfunction, and community violence – to an increased likelihood of negative health outcomes. In youth, trauma can cause behavioral issues, asthma, and infections; as adults, those same individuals are at greater risk of heart, lung, and autoimmune disease, obesity, mood disorders, and substance use disorders. This is magnified when you include income disparities and the impact of systemic and structural inequities.Image projected on a building of a younger Rep. Cummings taken on a street in his native Baltimore. From an unknown source, projected images and messages appear on the side of a building near my house in the Mt. Pleasant neighborhood of Washington, DC.When the news alert came across my cell phone on Thursday morning that Elijah Cummings had died, I felt overwhelming sadness for the loss of a powerful, eloquent, and soulful human who understood trauma in his bones. An immediate second thought was he died too soon as do many other African Americans whose lifespan is shorter by years than white people s. Then I wondered how we can honor his legacy by building on what he started dramatically in the House Oversight and Reform Committee with the first hearing of its kind on July 11 this year (Click here for a story on the hearing in ACEs Connection).Just the day before the news of Cummings’ death, I had read an email from Dan Press who leads the advocacy work for the Campaign for Trauma-Informed Policy and Practice (CTIPP) updating me and other members of the CTIPP Board about the latest thinking of Cummings and his staff about the advisability of moving ahead at this time with comprehensive legislation on trauma. The strategy was fluid but it was clear that Cummings was engaged and focused on the what, when, and how of promising next steps with legislation.Iowa ACEs Policy Coalition joins Iowa Gov. Kim Reynolds as she signs a Resilient Iowa proclamation in 2018. Photo courtesy of Lisa Cushatt.For years, advocates for a statewide children’s mental health system would stand before Iowa legislators and speak passionately about their own particular concerns.Psychiatrists pointed to a need for more inpatient beds for youth with severe mental illness. Pediatricians said the answer was better screening to identify mental health issues in children from birth to age five. Educators wanted more school-based mental health services, and advocates from grassroots groups like the National Alliance on Mental Illness (NAMI) asked for increased crisis services.“We were all saying, ‘Throw money at this issue,’” says Chaney Yeast, co-chair of the policy coalition ofCentral Iowa ACEs 360, a multi-sector network formed in 2012. “That confused legislators; they felt it was this black hole, and they didn’t act.”This year—thanks in part to connections forged by Iowa ACEs 360—advocates for a comprehensive child behavioral health system told a single story:Children whose mental health needs are met will be more likely to graduate, be employed and become productive members of the community. Current mental health services for children are fragmented and inconsistent. We know what it would take to fix that.Group after group that testified before Iowa legislative committee members—officials from the sheriff’s department, mental health providers, community advocates, child welfare workers—drummed home talking points that the ACEs policy coalition had developed with a public policy messaging and research firm.“That common messaging hit home. We were all on the same page,” says Yeast. The bill—which requires Iowa counties to implement a coordinated array of preventive, diagnostic and treatment services for children, and calls for parents of children with mental health issues to have a voice in designing those services—passed the legislature in April and was signed by the state’s governor in May.“That was a huge win in terms of collaboration,” says Yeast. It was also a clear example of the power that cross-sector networks can wield when members move beyond their own silos to support a shared goal. Such work is not easy—“It takes a lot of time and effort to continually nurture those relationships and connections,” says Yeast—but it is essential to making long-term, systemic change.That’s been theambition of Iowa ACEs 360 since its start, when a small group of stakeholders—in public health, mental health, family support and community advocacy—gathered, with the support of theMid-Iowa Health Foundation(MIHF), to discuss the original CDC-Kaiser Permanente ACE Study and how their work needed to change in response.That group decided on two priorities: collect Iowa ACE data and spread awareness of the ACE Study, so others could be galvanized by its findings on the lifelong, corrosive effects of early childhood adversity.After Rob Anda, the co-investigator of the 1998 ACE Study, did a presentation about the ACE Study to a small group of key stakeholders, an early step was to include the ACE module in Iowa’s Behavioral Risk Factor Surveillance System (BRFSS). Following an invitation-only summit in 2011 that featured a follow-up with Anda, he andLaura Porter, a nationally known expert on ACEs and population health, spoke to 800 people at the 2012 Iowa ACE Summit.Suzanne Mineck, president of MIHF and one of the original committee members who launched ACEs 360, says “water cooler conversations” in the weeks following Anda’s visits that gave the work momentum. “We all had the privilege of learning about compelling research, but it was the lingering impact, both on those in decision-making places and those on the front lines, that was as much of an ‘aha.’”As the coalition grew, hosting quarterly learning circles, developing work groups and, in 2014, acquiring a part-time program manager, it became a place where people from various sectors—juvenile justice, child welfare, health care and education—could learn together.“It created a culture where there wasn’t a singular response…a culture of transparency, humility, honoring and supporting risk-taking,” says Mineck. “Many felt they were learning things for the first time together.”Florida State University has launched a new online curriculum for a professional certification in trauma and resilience.The curriculum was developed by the Clearinghouse on Trauma and Resilience within the Institute for Family Violence Studies at the FSU College of Social Work in conjunction with the FSU Center for Academic and Professional Development.“This training addresses a gap in the knowledge base of human services professionals,” said Clearinghouse Director Karen Oehme. “Many professionals do not receive training on the impact of how to provide services to someone who is experiencing the harmful effects of trauma.”The course enables professionals to develop the knowledge and skills they need to understand the impact of adult and childhood trauma, along with the keys to resilience. Participants will learn crucial information to improve service delivery to clients, students, human services recipients, patients and other members of the public.The self-paced curriculum includes 20hours of course content and 10 chapters of research-based readings, case scenarios, multimedia materials, assignments and quizzes.The multidisciplinarycourse has been approved for continuing education creditsfor a diverserange of professionals including licensedcounselors, social workers, nurses, dentists andlawyers.Participants outside of Florida can submit their certification to their own licensing board to determine credit awarded.“The course is designed for professionals in a wide variety of fields because individuals in all different environments have exposure to trauma,” Oehme said. “We wanted to provide an economical, evidence-based resource to the public for those who want to enhance their professional knowledge, skills and career potential.”The curriculum is based on developing an understanding of adverse childhood experiences and the associated long-term negative effects. The training offers a powerful new perspective on trauma-informed approaches to effective service delivery.“Florida State University recognizes that professionals from all backgrounds have the ability to help individuals build resilience,” said Jim Clark, dean of the College of Social Work. “But first they have to learn about why resilience is so crucial in treating the negative impacts of trauma.” Clark said that FSU realized the need for such a course as it was developing theStudent Resilience Proect.“Our community partners have told us time and time again that they need research-informed resources,” Clark said. “It was a natural next step for the Clearinghouse on Trauma and Resilience to develop such a course.”Faculty from across Florida State’s campus participated in the review of the new course.Mimi Graham at the Centerfor Prevention EarlyIntervention Policy, a leader in trauma-informed education, served as a reviewer, along with 10 other faculty members.“FSU is a leader in trauma and resilience education for the public,” Graham said. “This course ensures that crucial information is available to our community leaders, so they can make trauma-informed decisions.”Joedrecka Brown Speights at the College of Medicine said, “It’s important for human services professionals to keep up with the new research on brain development so they remember there is always hope for healing after trauma.”Chapters in the certification cover the mental and physical effects of trauma, cultural considerations in trauma research, skills for addressing trauma and an interdisciplinary approach to building resilience.Professionals are required to review all of the course material and pass the chapter quizzes and final exam. When professionals complete the training, they will receive their professional certification from the Center for Academic and Professional Development. Photo by Ian Sheddan via Flickr Creative Commons_______________________________It’s no surprise that serious childhood trauma can lead people to use opioids. In the absence of healthy alternatives and an understanding of how experiences — such as living with a parent who’s alcoholic or depressed, divorce, and being constantly yelled at when you’re a kid — can make your adult life miserable, opioids help many people cope with chronic depression, extreme anxiety and hopelessness.But a new study has shown the significance of ACEs and ACEs-science-informed treatment: Each additional type of adverse childhood experience increases a person’s risk of relapse during medication-assisted opioid treatment by a whopping 17 percent. And each visit to a clinic that integrates trauma-informed practices based on ACEs science reduced the relapse rate by two percent, which can carry a person perhaps not to zero, but to a minimal risk of relapse.“This research clearly shows the lasting impact that ACEs (adverse childhood experiences) can have,” says Dr. Karen Derefinko, lead author and assistant professor in the Department of Preventive Medicine at the University of Tennessee Health Science Center, and director of the National Center for Research of the Addiction Medicine Foundation. “I think it’s the first research to connect ACEs to relapse.”Researchers from the University of Tennessee Health Science Center and the University of Memphis also found that more than half (54%) of people in a rural Tennessee opioid clinic relapsed, and the highest relapse rate was on the first visit. Almost half of the 87 people who participated in the study had an ACE score of four or higher — the average was 3.5, which is remarkably high. The study, “Adverse childhood experiences predict opioid relapse during treatment among rural adults”, appears in the September 2019 issue of the journal, Addictive Behaviors, and was published online last week.Dr. Karen Derefinko“This study will help practitioners understand the importance of providing trauma-informed treatment,” says Derefinko. “Because of the stigma associated with drug use, it’s hindered health care workers’ understanding of why people use drugs and has led to an assumption that they’re bad people. This shows that trauma-informed care and providing resources does impact how well people can do. It’s also validating for patients and gives them a lot of hope.” Continue reading Share this:EmailPrintFacebookLinkedInTwitterRedditTumblrPinterestLike this:Like Loading... Melinda Coates experienced a tumultuous pregnancy. “I was really mentally upset literally from day one (of the pregnancy),” she says. (Melinda Coates is a pseudonym. To protect her and her children’s privacy and safety, we are not using her real name.)Coates had hoped to get counseling last October, when she was seven months pregnant. That’s when she enrolled in the state’s Medi-Cal program, shortly after she and her abusive husband moved to California, “but nobody was able to get me in that quickly,” she says. “If I had gotten the help that I needed with my mental state, I may not have stayed in my abusive marriage as long,” she says.Six weeks after her son’s birth she had one session with a counselor who prescribed an antidepressant. “I was supposed to go back, and I needed to reschedule, but I never heard from her again,” says Coates, who has been living in a domestic violence shelter since the end of June with her eight-month-old son and three-year-old daughter. She is currently separated and filing for a divorce from her husband.A new policy in California that went into effect in July now makes it possible for pregnant women like Coates to get the counseling they need, according to a recently-released MediCal bulletin. Continue reading Share this:EmailPrintFacebookLinkedInTwitterRedditTumblrPinterestLike this:Like Loading... Photo: Vernon Bryant, Dallas Morning NewsAlmost the first thing you hear out of the mouths of police after a mass shooting is: “We’re looking for a motive.”In Gilroy, CA, the FBI is investigating the shooting at the Gilroy Garlic Festival as domestic terrorism. In El Paso, TX, police are describing the shooting as a possible hate crime and act of domestic terrorism, and focusing on the manifesto written by the shooter. Police in Dayton, OH, are still looking for a motive for why 24-year-old Connor Betts murdered nine people in 30 seconds.But if we want to prevent shootings, asking about motive will just get you a useless answer to the wrong question. Police might feel as if they have an explanation for why 19-year-old Santino William Legan murdered three people, and why 21-year-old Patrick Crusius murdered 22 people. But motives don’t explain the roots of why those three young men, or any other mass shooters or bombers, foreign or domestic, start their journey as innocent babies and end up on a road to killing people. And in those roots, are our solutions.If you use the lens of the science of adverse childhood experiences, the answer reveals itself, and usually pretty quickly. Continue reading Share this:EmailPrintFacebookLinkedInTwitterRedditTumblrPinterestLike this:Like Loading... RT @ACEsConnection: Excited to have had more than 2400 members of ACEs Connection sign up to view Broken Places! Eager to hear how you will… 1yearago

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