00:01 Sally Laskey: Welcome to NSVRC Resource On The Go. My name is Sally Laskey, and I am the evaluation coordinator at the National Sexual Violence Resource Center. Today, I'm joined by researcher Sabrina Liu. Sabrina graduated with her PhD in Clinical Psychology from the University of California, Santa Barbara, and is now a post-doctoral fellow at the UC Irvine Conte Center, where she studies how pre and postnatal exposure to adversity impacts child development. She has expertise in the areas of psychological trauma, adverse childhood experiences, resilience, cultural diversity, child mental health, and integrated behavioral healthcare. In this episode, we discuss her research on understanding and improving mental health and mental health inequities among children and families from diverse and underrepresented backgrounds, particularly those who have faced trauma and adversity.

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01:16 SL: Welcome to the podcast, Sabrina. When I read your article, "Don't Start and End with ACEs: How Protective Factors Explain Youth Health" in the American Journal of Community Psych, I knew we had to have you join us. Could you tell our listeners a little bit about yourself and your journey with this research on protective factors for youth? 

01:39 Sabrina Liu: Absolutely. And thank you for having me on this podcast. So in terms of my personal journey towards this work, I think I was always interested growing up in youth development, and when I went to college, I knew I wanted to work with kids eventually as my career. But I wasn't sure exactly what I wanted that to look like. So I had the opportunity to volunteer in a few different positions, where I got to work with kids in various settings. So I worked as a student mental health counselor and as a mentor and a tutor, and I also worked at a social services agency as a case worker. So all of these were free social services programs serving under-resourced communities, and I had a lot of opportunities to work with really diverse groups of kids and learn more about them. And I was definitely naive and privileged in many ways at that time.

02:44 SL: So, I came to this realization that might be surprising to some, that I didn't have before, but I realized that because of where these kids were from, or the circumstances that they found themselves in, they were more likely to be exposed to certain types of hardships and adversities, and actually then those experiences continued to put them at risk for further hardships and further adversities in what was sort of a vicious cycle. So I think of an example of one boy I worked with. He came to meet with me for assistance looking for a job. And I learned that he was a recently arrived refugee, and he had been living in a homeless shelter with his family, but had a steady job and was feeling hopeful towards his future, and working on achieving some goals that he had. But one night, coming home from work, he was pretty brutally mugged and robbed and ended up in the hospital for several days, and because of that, he didn't show up for work and lost his job, and so that's why he was meeting with me, to look for new jobs.

04:05 SL: And so, I saw that type of experience again and again where, for every few steps forward a lot of the kids I was working with had, something would happen that would put them a few steps back from achieving their goals. And at the same time, I saw that every time they were getting knocked down, they were getting back up and surviving and thriving in the face of these adversities. And of course, that wasn't true for all of the kids that I worked with, but really I saw that persistent pattern again and again. And so that led me to want to learn more about what can make kids so resilient in the face of adversity, and that's what led me to, I think, eventually pursuing my PhD in Clinical Psychology.

04:48 SL: Thank you so much for sharing that very specific experience. I think when folks invite us into their lives, it really does shape and change our own. And I'm wondering if this and other experiences like that helped you get interested in ACEs, and if you could tell us more about your interest and work around ACEs.

05:21 SL: Definitely. So when I began to learn about ACEs and ACEs science, it was like I was understanding, in the research, what I had seen in all of my direct service work. So ACEs stands for Adverse Childhood Experiences, which typically refers to childhood experiences of abuse and neglect and household challenges. So things like having a family member with mental illness or having a family member incarcerated. And there's been more than 20 years of research on ACEs now that have shown a couple really striking things.

06:03 SL: The first is that they're really common, so two-thirds of the US population has at least one ACE. And if you have one ACE, you're more likely to have additional ACEs, so that's kind of what I was referring to when I said I could relate to seeing how there's that cumulative impact of adversities that kind of tend to pile up across the life course. And the other thing we know is that ACEs have a really robust link to later-life poor health outcomes. A whole range of different poor physical health outcomes, health risk behaviors, and what researchers have called life potential outcomes, so ACEs are also linked to things like lower graduation rates.

07:00 SL: So yeah, and so the thought behind the connection between ACEs and poor health outcomes is that it's related to the persistent, chronic, intense stress that ACEs have on people. So it's like having your flight or fight response constantly activated in a way that that system in our body actually starts to break down and impact our physiological systems, and have wear and tear on our body. So there was a lot of really great research on... That we're starting to understand about why ACEs impact our health in this way, but I think there was less research that talked about resilience in the ACEs narrative, and so that's what led me to wanting to really understand what can be protective in the face of adversity.

08:00 SL: I'm really excited to talk to you more about protective factors as a community psychologist, and as someone that is working to learn and understand more about community-level prevention strategies. I was really struck by your specific approach and methods in your research. Could you talk about the specific framework that you use for this research project? 

08:32 SL: Yeah, definitely. So kind of what I was already saying, I wanted to continue to look at ACEs and understand how ACEs impacted youth health, and I wanted to, in conjunction with that, also look at protective factors or factors that can mitigate the risk of ACEs on health outcomes. And there's been a lot of research done on individual protective factors that can promote well-being in the face of adversity, so a well-known one is, for example, if kids have the presence of just one adult, caring adult in their lives. That's been shown to have a tremendous impact on later outcomes in their lives.

09:18 SL: But I think less research has looked at the cumulative impact of different types of protective factors in the same manner that we've looked at different types of ACEs. And we know, again, speaking from more of this community psychology perspective, we know that youth exists in so many different environments that impact their development. So they exist in families and in schools and neighborhoods and societies, and there's factors that exist in each of these environments that can positively or negatively impact development. So for example, the presence of after-school programming or not, or what neighborhood resources are or are not available. So I chose to use what is called a person-centered approach to my data analysis. So I was looking at a nationally representative sample of black, white and Latinx youth, and I was able to identify typical patterns of experiences of different types of ACEs, as well as different protective factors from these different environments that youth exist in. And then I was able to look at how together, these typical experiences of ACEs and typical experiences of protective factors interact to influence health outcomes.

10:40 SL: Well, I think that gets us all ready to wanna hear about your results. What did you learn? What did you find in your study? 

10:48 SL: So I think if I had to distill down the results of my study to some key findings, the first thing that I would want people to know is that I saw that youth with greater access to protective factors were healthier than youth with the same levels of ACEs, but fewer protective factors. So again, just really reiterating that fact that protective factors make a huge difference, and the youth who are doing the best were those that actually had the presence of protective factors across these different socio-ecological levels of family and school and community context.

11:25 SL: So for example, a protective factor within a family might be having strong levels of communication between a parent and child, whereas on a community level, might be the opportunity to be involved in different community activities. And then the second major finding I had was that there were consistent racial and ethnic disparities across ACEs and protective factors and health. So on average, Black and Latinx youth had higher levels of adversity and lower levels of protective factors compared to white youth in my sample. And this is very likely wrapped up in structural racism in our country. So for example, we know that certain laws and policies in our nation's history have led to accumulating wage and wealth disparities between families of color and white families or... So it makes sense that black and Latinx youth in my sample were more likely to endorse the ACE of facing economic hardship, in the same way that there's been law enforcement practices and criminal justice policies leading to more incarceration of black and brown people.

12:44 SL: So again, those youth in my sample were more likely to endorse the ACE I had of having a family member who was incarcerated. And then I also saw that the health of black and Latinx youth in my sample was worse than the health of white youth, even when they had equivalent levels of ACEs and protective factors. So again, I feel as if there was several factors in my results that I wasn't able to account for that were explaining some of these disparities, but racism was certainly a major factor here, because we know that chronic exposure to racism increases vulnerabilities to stress, that then have this long-term impact on health outcomes. So if we think about the additional racism that youth of color in our country experience, it makes sense that we would see those disparities in health, even when we're accounting for other types of ACEs and protective factors.

13:43 SL: So altogether, if we're thinking about what are the implications of these findings for policy or practice, I think, if we're thinking about trying to get to the root cause of some poor child health outcomes, we can certainly think about targeting ACEs. And there's been a lot of discussion and movement towards trying to prevent or address the impact of ACEs, and at the same time, the results are really suggesting that protective factors are just as important to focus on in terms of promoting them. And in both all of these initiatives, they need to be done through this lens and understanding of systemic inequities and drivers of racial and ethnic disparities in this country.

14:34 SL: Sabrina, your work is really, I think, timely, of course. But as we are trying to connect the dots between different systems of oppression, and really looking at anti-racism work as being critical to preventing sexual violence, I think your results provide some really important lessons for the community-level approaches that we're really trying to examine and try out and use different strategies. In thinking about our core audience being folks that are working to prevent and address sexual violence, do you have any specific lessons or things that you learned that you think are relevant to those audience members' needs? 

15:31 SL: Yeah, I think certainly. So we know that ACEs are linked to sexual victimization in adulthood, much in the same manner that they're linked to other poor health outcomes. So for every additional ACE a person has, that increases their risk for sexual victimization. So any strategies that are taken to prevent and intervene with ACEs should also have this protective effect on the risk of sexual victimization. So going back to this idea of not just intervening with ACEs, but promoting protective factors, there were a number of community protective factors that emerged in my research that can be and are being targeted through community-level intervention and programming.

16:22 SL: So things like having access to a mentor in the community, or having the opportunity to be involved in after-school activities like sports or certain clubs, as well as community service options for youth. So I think promoting these types of programs is important. And some of them even could have an explicit focus on sexual violence. So for example, service opportunities for youth to be involved in that involve psychoeducation and advocacy around sexual violence could be really neat, but even I think if these programs don't necessarily have that specific focus on sexual violence, we should still see that protective effect emerge, that will have that trickle-down effect on mitigating risk related to sexual violence.

17:18 SL: And you also mentioned connecting the dots between different types of oppression, and much like ACEs, we know sexual violence disproportionally impacts communities of color and low-income communities, because of largely structural racism. So all of these initiatives, again, have to be culturally responsive, and done through this lens of social justice and anti-racism, like you were saying. And this is something important for the field of psychological research as well, and I don't think it's always been done, but there are certain methodologies which build in these principles of equity and justice. For example, participatory action research methods like CBPR, which stands for Community-Based Participatory Research.

18:11 SL: This is a method that incorporates community members' voices and their wisdom at every step of the way, from coming up with the research questions, all the way to disseminating the results, and deciding what the implications are. So that really allows, I think, for the research to ensure that the research is meaningful and responsive to community needs. And this is also something that can be done with youth, so with youth as the community partners in really creative ways. And I think when the research has a social action mission and is done through this type of partnership, it can be just a very empowering process for everyone involved. So that's some of the principles that I think are important when we're thinking about doing psychological research. And I imagine that some of those same principles can be applied to this community prevention work, and probably already are being applied to this community prevention work. Yeah.

19:14 SL: Thank you for that. I appreciate your perspective, and we certainly know of folks that are using those approaches. I'm wondering, I hadn't planned on specifically asking you about this, but I wonder if you and the team of folks that you've been working with and the youth that you've been engaging with. Do you have any thoughts about these community-level protective factors, and what those might look like as people are social distancing, engaging in protests, and working in virtual spaces? Just if you have any ideas. I know that wasn't the focus of your research, but if you've thought through any of that, I'd love to hear your thoughts.

20:06 SL: Yeah, I think that this is unprecedented times where we're having to so quickly adapt any established systems or programming that we had to this social distancing world. And so certainly, I imagine that there's ways to promote these protective factors in a safe, socially distanced way. But again, so things like having virtual mentorship programs, or getting kids involved in advocacy, perhaps more through social media and online avenues rather than being out in person, are things that I'm thinking of right now.

21:10 SL: That's great. We're actually gonna be talking a little bit more at a future podcast about sex education through social media and other technologies, so I think we can help make some other connections on the topic, but thank you for just kind of thinking through some of that with me. If we continue to look at applying the current and compounding community traumas of COVID-19 and police brutality against black and brown people, what do you think would most help protect and support the health and resilience of youth moving forward? 

21:53 SL: Yeah. Yeah, I wanna speak to that question, but also, as you were talking, I had this thought about... As you were talking about sexual education through social media, I think, again, youth are some of the foremost experts on social media, and I think sometimes are more adept at using that than adults, and so that could be a really cool way to bring in the expertise of youth in these types of initiatives, and make them feel like valued partners that really can be catalysts of change in those types of initiatives. So I think that that's... Thank you for sharing that.

22:42 SL: And yeah, so to speak to your question about supporting the health and resilience of youth during this time, exactly like you're saying, we're seeing widespread stress and trauma due to current events, particularly COVID-19 and police brutality and the movement for racial justice. And again, these stressors are impacting all of us, but they're not impacting all of us equivalently. So they're certainly disproportionately impacting communities of color, and I think keeping that in mind, we can pull on what we know about resilience in the face of adversity, and apply it to this context.

23:31 SL: So in terms of community programs, I think it's important to think about Maslow's hierarchy of needs, so that basically says that before we can think about getting our psychological needs met, we need to be thinking about getting our basic needs met, which are of course under threat perhaps now more than at other times. So programming that's just focused on helping families get safe housing and access to food and job support and accessing government aid, I think those are really crucial right now. And then on top of those, on top of kind of getting our basic needs met, then we wanna start thinking about these next-level interventions that can promote emotional well-being during such a stressful time.

24:20 SL: So some things that occurred to me, I was thinking about programs that promote access to mental health services, programs that are helping parents manage with kids at home, so perhaps tutoring programs, or parenting support programs, and then again, exactly like you've been saying, all of these programs need to be considering how they're gonna access families and help them remotely, and do families have the resources they need, the technology and internet support, to be able to make the most of these resources? And then I think specifically when we think about the social isolation that is occurring from COVID-19, and just heightened levels of racism and discrimination. Any organizations that are able to promote a sense of community and belonging and social support are gonna have that dual impact of protecting against the stress of both COVID-19-related isolation as well as racism. Social support and belonging and community have been shown really over and over again in the research to be enormously protective against the stress of racism, so I think that those are some really important programming considerations.

25:52 SL: Sabrina, speaking of belonging, I'm glad to belong to a community where we're learning from you and your other research team members. I'm so grateful to the youth that you partnered with on this research, and I think it's gonna help us in moving forward. Do you have any kind of final thoughts to leave or to conclude our discussion with before we wrap up? 

26:22 SL: I just wanted to thank you for giving me this opportunity, and for all of the great work that you're doing. And for starting this podcast. It's exactly an example of what we're talking about during this time when we are so much more socially disconnected in so many ways. This is a way that a group of like-minded people that care about the same things can really connect together on some really important issues, and think together about how to address them. I know that we're gonna include some more resources about coping with COVID-19, and addressing the impact of racism on youth, as well as ACEs and protective factors in the show notes as well.

27:10 SL: We are. So I wanna thank everyone for listening. Dr. Liu, thank you so much for being with us. We'll have a blog post coming up on this topic, and some additional resources for parents and for folks looking at community-level prevention strategies, and ways that we can build healthy communities. So thank you all for joining us, and we look forward to having you join us on our next episode.

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27:46 SL: Thanks for listening to this episode of Resource On The Go. For more resources and information about preventing sexual assault, visit our website at www.nsvrc.org. You can also get in touch with us by emailing resources@nsvrc.org.