ACES in the Arctic

Addressing ACEs and building resilience in circumpolar communities -- Denmark, Finland, Norway, Alaska, Sweden, Iceland, Russia, Canada.

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TOOLKIT UPDATE

Our Toolkit, called "Hard Times and Healing: Addressing the Intersections Between Domestic Violence and Other Adverse Childhood Experiences (ACEs)" was launched at a statewide training with domestic violence advocates in Alaska at the end of February.   In collaboration with the Washington State Domestic Violence Coalition and several tribes in Washington, the Toolkit will be shared through a series of training events in May, 2017.

The concept of creating a toolkit on ACEs for domestic violence service providers and community partners, was conceived during the Fulbright Arctic Initiative, 2015-16.   With support from this Initiative, I conducted focus groups with domestic violence shelter directors and staff in Finland to examine how past and current co-occurring adverse childhood experiences, in addition to domestic violence, may influence and inform best practices for working with children exposed to domestic violence, adult survivors and domestic violence offenders.   At the same time, as Director of the Alaska Family Violence Prevention Project and in partnership with the Alaska Network on Domestic Violence and Sexual Assault, we conducted a statewide survey of domestic violence shelters using questions similar to those asked with focus groups in Finland.  One of the key findings from both the quantitative and qualitative data was that an open access toolkit that provided information to understand the intersection between domestic violence and ACEs and that included simple strategies to promote resilience, self-regulation and healing would be useful.  Findings from the on-line survey and focus groups with domestic violence shelters are being presented at several national conferences in the United States and in Sweden and Finland this spring and next fall.

The Toolkit is in the format of a PowerPoint presentation that is usually delivered during a half-day training.  Informed by the latest science, the toolkit uses simple concepts such as the "Upstairs-Downstairs" brain graphic to provider user-friendly information that can be used with clients.

The Toolkit is only available in English at this time but it is hoped that users may translate it in the future.  The following topics are addressed in the Toolkit:

  • Trauma-Informed Approach
  • Focus on Strengths and Skills → Understanding Resilience
  • Vicarious Trauma
  • The Brain and Stress
  • Intersections Between Domestic Violence and Adverse Childhood Experiences (ACEs)
  • Simple Strategies to Promote Resilience, Self-Regulation and Healing

Having recently trained as a Capacitar facilitator, the second part of the day, when scheduling allows, is dedicated to teaching Capacitar, an international model that uses multiple modalities including breath work, movement, acupressure and easy to learn techniques for self-care, healing and preventing vicarious trauma.  This skill-based approach builds on content in the toolkit.  

Following the trainings in Washington State this May, final edits will be made and the Toolkit will be posted on this site in late summer.  For any questions or comments, please contact Linda Chamberlain at drlindachamberlain@gmail.com

 

What other ACE surveys have additional questions?  We know of seven.

We’ll start to populate the new Resource Center next month. One of the sections lists ACE surveys that have additional questions. 

The CDC-Kaiser Permanente Adverse Childhood Experiences Study revealed that ACEs contribute to most of our major chronic health, mental health, economic health and social health issues. 

It measured five types of abuse and neglect: physical, verbal and sexual abuse; physical and emotional neglect. And five types of family dysfunction: a family member with mental illness, or who has been incarcerated, or is abusing alcohol or other drugs; witnessing a mother being abused; losing a parent to divorce or separation.

Of course, there are other types of childhood trauma, and there are ACE surveys that include other types of trauma, based on the experiences of the population surveyed. These other types include racism, bullying, witnessing a sibling being abused, witnessing violence outside the home, living in an unsafe neighborhood, experiences unique to being an immigrant (such as losing a parent to deportation), and involvement with the foster care system.  

So far, we know of seven ACE surveys that have additional questions. We're searching for more. If you know of others, please leave a comment so that we’ll have a list that's as complete as possible:

1. The Philadelphia Urban ACE Study added five other ACEs — witnessing violence other than a mother being abused, experiencing discrimination based on race or ethnicity, feeling unsafe in your neighborhood or not trusting your neighbors, bullying and ever in foster care;

2. Children's Clinic pediatrician The ACE survey used by the Children's Clinic in Portland, OR (but I just heard that Dr. RJ Gillespie, who's managing the project has changed the additional questions, so I'll look into that);

3. Center for Youth Wellness ACE surveys (Dr. Nadine Burke Harris), which add six additional questions; 

4. The Roseland Clinic in Santa Rosa (I don’t have a link to their survey yet);

5. The World Health Organization ACE questionnaire; 

6. The Family Center's ACE survey, which asks the 10 questions in different ways, to accommodate to the language used by the people who take its survey to describe particular types of trauma; 

7. Elsie Allen Health Center's survey, which asks six additional questions.

Research in Finland Begins!

My research with the Fulbright Arctic Initiative in Finland has begun!  I have met with two domestic violence shelters/programs in northern Finland and have now crossed back over the Arctic Circle and am at the University of Jyväskylä for several weeks to learn about the highly innovative research they are doing on the emotional security of children before I continue on to interview domestic violence shelter staff in several more locations in central and southern Finland.    My final meeting with be with the Federation of Mother and Child Homes and Shelters which supports all of the domestic violence shelters in Finland.

What we learn from the interviews will compliment the survey of domestic violence shelters that is currently underway in Alaska and provide a diverse Arctic perspective on  making the connection between domestic violence and Adverse Childhood Experiences (ACEs) and how we can apply what we have learned to our work with children and parents.  While it is still early days in this project, I am encouraged by the interest in a resource on ACEs for domestic violence service providers--for me the end product of my project is not the data but rather an open-access training resource !

Meanwhile, I am deep into a literature review of ACEs in the eight countries with Arctic regions.  I discovered, quite accidentally, that Finland has published extensively on "childhood adversities" and figuring out that slight change of wording was key.  There is some overlap in the types of adversities assessed in the Finnish research with the ACEs research  in the U.S. and the Finnish studies bring an important dimension to the body of ACEs research not only because of parallel findings in a different population but because these are  POPULATION-BASED PROSPECTIVE STUDIES!   I did not anticipate the number of publications that have been done here in Finland and am also looking at some similar research on childhood adversities in Sweden which again involves longitudinal research....but enough about this as I know it's the kind of information that may only excite an epidemiologist!!

Suicide Rates Rise in the U.S.

 I became extremely interested in suicide prevention after two of my young cousins committed suicide within six months of each other.

I began to study the current state of suicide prevention in 2008 and began to envision what I refer to as a future state in about 2009. I wrote a very quick paper summarizing my research because two of my dear friends were deeply engaged in suicide prevention, one as chair of a prevention task force and the other as a teacher, coach and mentor.

I gave three presentations in 2011 about what I believed was a proper approach using an identification of ACEs approach. I refined that until I wrote up a “Restoration to Health Strategy” that addressed both behavioral and health issues. My approach is systemic and starts as soon as we can identify the infliction of ACEs and related behaviors, positive, neutral and negative. Healing is a five-step approach addressing assessment and knowledge, nutrition, trauma release, self help and professional help. It is my hope to start a dialogue around a holistic approach to health, and not just one centered in healthcare, behavioral health, child protection systems and other current entry portals. In that discussion, we should be able to identify the symptoms of ACEs and how it progresses into actual suicide ideation and attempts. 

Thanks to a post on ACEsConnection, I was introduced to the Frameworks Institute [LINK HERE] and its work on how to identify frames used by people to discuss issues with the purpose of reframing topics for discussion in a manner that does not trigger original frames and trigger defensiveness. It’s a brilliant theory with incredible potential for reframing many of the discussions around ACEs. 

A recent New York Times article, for example [LINK HERE], makes no mention of ACEs, but points to many of its symptoms as causation. I believe that unresolved childhood trauma is a significant contributor to suicide, and that the same trauma is responsible in part for many of the symptoms. Think about the relationship between ACEs and high school dropouts. If you are a dropout, your economic security will be challenging, and you are very likely to be poor in your later years. Being poor in later years can contribute to additional stress that might take your ACE condition and propel it into other symptoms that eventually lead to suicide. This chain of causation can be difficult to follow, but I am hopeful that researchers will start looking down that causation chain from ACEs to suicide.

In Alaska, our suicide rate is increasing as well. It’s already high among Alaska Natives, and that is predictable. Pat Sidmore, a state of Alaska researcher on ACEs, summarized the results of the Behavioral Risk Factor Surveillance System data from 2013 as identifying Alaska Native with almost double the risk of having 4 ACEs than the general population has. [LINK HERE]

I did a search for any analyses using the Frameworks Institute model, and asked my colleagues on the American Indian/Alaska Native Task Force on Suicide Prevention whether any of the were aware of a Reframing Analysis. No one had heard of the theory nor any work to use it. I would like to ask you if you are aware of any use of Reframing within the Suicide Prevention community. And do you have ideas about how we might reframe the discussion about ACEs to become more systemic? After all, the original study started out studying health and identified a host of other behavioral issues -- it was a systemic result. 

 

BRIDGING THE GAP: DOMESTIC VIOLENCE AND ACEs SURVEY

The Alaska Family Violence Prevention Project, in partnership with the Alaska Network on Domestic Violence and Sexual Assault (ANDVSA), our statewide coalition, has launched an on-line survey about Adverse Childhood Experiences (ACEs) that was sent to the executive directors of all member domestic violence shelters/advocacy programs in Alaska.  Nearly half of the survey recipients responded the week the survey went out .

 The questionnaire, which started with a brief explanation of what ACEs are,  consists of eight questions that ask about staff training on ACEs, the potential implications of ACEs for services provided to adults and children, what types of information about ACEs would be useful for staff,  and considerations, challenges and concerns about addressing ACEs in their communities.  The survey data will be used to inform the development of a Train-The-Trainers on Domestic Violence and ACEs for domestic violence advocates in February, 2017.  This event, sponsored by ANDVSA, will be a crucial first step to share all that we are learning about the connection between domestic violence and ACEs with domestic violence service providers and to identify opportunities for collective impact, partnerships and funding while ensuring the safety of adult survivors and their children and promoting trauma-informed practices.

State of Alaska Playing Catch Up

As one who has been advocating for change in addressing childhood trauma for many years now, I have learned that change is extremely difficult for most people. There needs to be a reason for it. When Dr. Felitti was in Juneau last week, his planned testimony before the House Health & Social Services Committee was cancelled. The Legislative leadership mandated no hearings could be held unless they dealt with the state budget deficit. It was odd because what Dr. Felitti has to say is of enormous benefit in reducing cost to the State of Alaska. We made up the time by talking to individual legislators about the benefits available through screening adult patients for childhood trauma.

Here is what Dr. Felitti told the House Minority Caucus. After the ACE Study results were complete. he had an offer from a professor with a new business to assess 130,000 online assessments. It was over two years of data, and what it showed was a 35% reduction in doctor office visits by patients who went through the ACEs assessment for a period of one year. That means that 58,000 patients with 3.2 annual visits would experience a reduction of about 65,000 visits annually. The cost savings for 65,000 visits is substantial. The online assessment was used in doctor office visits at Kaiser Permanente to address patient medical and trauma issues.

In about 2004, Dr. Chuck Grim, head of the Indian Health Service (IHC), encouraged as one of his initiatives the integration of behavioral health with medical care. Unfortunately, there was little guidance like that available at Cherokee Health Systems, and most health care systems in the IHS used a variant of the PHQ-9. Most patients found the questions offensive or intrusive and many systems reduced them to two questions: Do you smoke? and Have you had more than X number of drinks in the past week? Neither question provides much information of any value to medical advice other than you should quit smoking or slow down your drinking. The benefits Dr. Felitti described do not work, in my experience, with the PHQ-9.

About 2010, I visited Cherokee Health Systems in Tennessee. At that time, they had decades of experience with an integrated behavioral health/medical center. Touring exam rooms, we saw stations for the behavioral health specialist next to the MD and medical assistant. They collaborated all the time on patient issues, and rightly so. Some of the research I conducted during this period of time revealed that many patients whom doctors saw had what were described as MUS (medically undiagnosed symptoms). A lot of the literature about MUS attributes the diagnosis to anxiety and stress. The symptoms are real, but there is no medical explanation. As we have learned in the ACE community, fear, anxiety and stress compromise our immune system and have symptoms that are real, but related to our childhood trauma. So the treatment is not medical, but behavioral. This knowledge has been with us for decades, but not adopted in medical facilities. Why? Well, what CEO wants to give up the 65,000 doctor office visits by using an online document to assess patients. More patients and more severe illnesses mean more income and greater profits.

So what advice are Alaska executives and government officials giving to the Alaska Legislature today, in 2016? Here is a link to an article about testimony from Alaska Commissioner of Health & Social Services and the head of the Alaska Mental Health Trust [LINK HERE]. The advice: “State leaders believe they can lower the long-term growth in Medicaid costs and make Alaskans healthier mentally and physically. They plan to do that by better coordinating  behavioral health care — the treatment of mental health and addiction.” The concept that has existed for decades and pioneered at Cherokee Health Systems is finally arriving in Alaska. I celebrate that, but wonder why the more current knowledge provided by Dr. Felitti and others is not getting the same type of consideration.

In recent years, health care growth has been the driver behind the Alaskan economy. It’s the  bright spot. Yet many proposed solutions have been discussed that would reduce the cost of health care by off-loading care to non-medical services. But because non-medical services aren't compensated for as health insurance is, they get treated in health care facilities. I am happy the conversation is starting, but it’s not a state-of-the-art conversation and it’s occurring during a time of considerable stress in health care. There are other solutions available that can pay for the $5 million cost, but it won’t be considered for a variety of reasons.

Let’s start the alternate conversation.

Visit to Juneau, Alaska, by Dr. Vincent Felitti

 

Dr. Vincent Felitti spent three days in Juneau, Alaska this week as a guest of the Sealaska Heritage Institute (SHI) and its president, Dr. Rosita Worl. He was invited to speak about the CDC-Kaiser Permanente Adverse Childhood Experience Study and how it might benefit Alaska, specifically the Alaska Native community.

Beginning with a radio appearance and a community reception with about 100 people in attendance, Dr. Felitti was well received. While in Juneau, he met with Alaska Native leadership, representatives of All Alaska Pediatric Partnership, the state pediatrics organization, state employees who are either using ACEs knowledge in their programs or considering its use, legislators, Gov. Bill Walker, Lt. Governor Byron Mallott, and representatives of the Alaska Departments of Health and Social Services and Corrections. A planned presentation to the Alaska House Health and Social Services Committee was cancelled by edict of legislative leadership, who said that only committee meetings on budget issues would be authorized. We quickly arranged a meeting with the House Minority Caucus and a member of the House Finance Committee, where there was considerable interest.

A real conundrum involved the cancellation of the hearing in deference to working on budget issues only. As Dr. Felitti explained to every audience he spoke to, a followup study of 130,000 Kaiser Permanente patients conducted over a 2+ year time period demonstrated a drop of 35% in patient visits for a one-year time period if they filled out a health assessment form. With eight million members in Southern California, and a budget for primary care of $6.5 billion, the impact of a 35% drop in visits would be considerable.

The public lecture presented by Dr. Felitti set records for Sealaska Heritage Institute attendance. Held in the Clan House at the new Walter Soboleff Building , about 140 people attended; an additional 40 to 50 people were turned away at the door due to lack of space. The lecture was videoed and will be made available online through SHI.

The Juneau Empire reported on the lecture in this story -- Speaker: Childhood trauma can lead to health issues.

The resolution introduced by Rep. Geran Tarr (D-Anchorage) as House Concurrent Resolution 21, was discussed with a number of Alaska Representatives and their staff. We made Gov. Walker aware of the Resolution and he agreed to review it and make a decision on whether to support it.

The visit exceeded my expectations and am hopeful that we can start to make progress with addressing state policy on addressing childhood trauma.

 

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