Empire Health Foundation is a private health foundation with approximately $165 million in assets under management and stewardship, working to measurably improve the health of communities in Eastern Washington. Don Ciavola, MSBR Director of Development and Communications, recently had the opportunity to speak with Mr. Chiang about Adverse Childhood Experiences, the focus of one of the foundation’s major strategic health initiatives in Spokane and Eastern Washington.
(The following is the complete transcript of an interview held on May 4, 2015)
Don: Although I have a couple of general questions on Adverse Childhood Experiences (ACES), I really want to make sure I give you the opportunity to discuss what you think is important.
Antony: Maybe I can give you a little bit of background about why Empire Health Foundation is working on ACES and why we’re particularly involved now in the child welfare system.
Don: That would be great.
Antony: Then we can go from there to see if you have specific questions.
Don: Perfect. Thank you.
Antony: What I’ll do is give a hundred thousand foot level first. I’ll start at day one. Day one is really when the foundation was created. We were created on the sale of Deaconess Medical Center & Valley Hospital. We have a very broad health machine. Five years ago, our board of directors chose two initial priority areas. We now have ten, but they chose two right out of the gate. Of those two, one priority was mental health. They didn’t have a specific definition of that. They just said that it’s an unmet and under-served arena, not only in our community, but in American society in general.
What became increasingly clear over the next couple years was that they wanted us to work in conjunction with the Affordable Care Act and be proactive regarding the changing access to treatment. And to not just be at the treatment end of the spectrum, but to go the whole length of the spectrum, get upstream, and do prevention as well.
Really, the metaphor in health care is: You’re a village pediatrician and you keep seeing child after child come down with this stomach bug, and pretty soon you’re up to fifty a day. At some point you stop and say, “Okay, well maybe I should go to the well and see who is putting infectious agents in the village water.” Or you’re an ER doctor. You’ve got fifty bleeding patients in the ER, and it’s not that you’re not trying to treat them, but at some point you need to stick your head above the fray and say, “Gosh, we used to have ten.” Get upstream and say, “Well, what’s the root cause of all this?”
The ACEs study, of course, is incredible in this respect. And the study itself is huge. The original work has over twenty thousand adult respondents and is amazingly meticulous in its methodology. Ultimately, it identified ten major areas of childhood trauma, such as recurrent physical abuse, emotional abuse, alcoholism or drug addiction in the household, emotional or physical neglect, domestic violence, sexual abuse, etc. Until the ACES study came along, I don’t think folks quite realized how complex trauma is at the root of so many of our most important health and mental health problems. It’s pretty phenomenal when you think about it.
Okay, tell me your demographic. Are you in your fifties?
Don: Yes, fifty nine.
Antony: Okay, in your fifties. Take two southern California patients, both with university degrees, both with the same income, same non-profit job, both in their late fifties, both Caucasian, both born and raised in southern California. For all intents and purposes, look alike clones.
Antony: It’s interesting. Dr. Felitti, even though he was the original catalyst for the ACES Study and his cohort, Dr. Anda, even they didn’t predict that with four or more ACES you don’t just have a twenty-six percent higher chance of a diagnosable mental health condition or disease, or even a two hundred and sixty percent chance. You have a two thousand six hundred percent higher rate of mental illness.
Antony: And it makes perfect sense, but some other things didn’t. Like why do you have a four hundred percent higher chance of cardiovascular disease? That’s weird, isn’t it? Traumatic events happened when you were seven or ten, and now you’re fifty-nine and you have a four times higher a chance than your clone of having heart disease or cancer? I know if I was the Doc’s I’d be scratching my head, but we’ve now had fourteen years of intervening research to ask, “What the heck is going on here?” They have the research technology now, such as imaging, and it’s starting to make total sense.
For example, everyone knows we’re wired for “fight and flight,” right? So imagine you’re going along a trail in the woods and you see a bear. What happens? Boom! Adrenalin, cortisol, tons of wonderful neurochemicals bathing the body to do what? Fight or flight.
The beautiful thing is that the human body is designed to come back down afterwards. It’s a short term survival response. But what happens when that proverbial bear is in your home every night? You grow up, your brain develops, your body develops, you’re hard-wired for “fight and flight.”
And guess what? That poor seven year-old has become a fifty-nine year old. His heart has continuously been in fifth gear, while yours revved up and down in a healthy manner. His heart is basically wearing out faster. It’s shockingly simple when you think about it.
Don: It is.
Antony: In mental health, we understand less about the brain than we do many other parts of the body, but the research is clear, experiencing trauma creates neurological damage in the brain. Most folks are familiar with Post-Traumatic Stress because they know or know of people in the armed services who suffer from PTSD. Here you have adults with fully formed brains who are highly trained. It’s not as if the Armed Forces are not aware of PTSD. For decades, they have been trying to build what they call resilience into our service members, but still, when people suffer severe traumatic experiences, like being in a war zone or having your buddies blown apart, it causes real damage to the brain.
Now imagine there’s a four or seven year-old with a developing brain and he experiences the same level of trauma while his brain is developing. Don’t you think there’s something happening to the wiring that has long term implications? If you’re an educator, and you’re in the classroom, and that seven year-old or thirteen year-old drops the F-bomb on you, your natural reaction may be to say, “Steve Doe, who the heck do you think you are disrespecting me in my class room. Go report to the principal’s office for suspension,” or whatever the case might be, when in fact, they are wired for fight or flight and something has triggered them.
That doesn’t mean the behavior is any less challenging. It doesn’t mean the behavior doesn’t need to be balanced in some way with some understanding of the consequences of that behavior. But the choice is, we can have a punitive response in the classroom or we can have a compassionate response in the classroom. In fact, in Walla Walla where we first started learning about ACES, they reduced their out-of-school suspension rate by eighty-five percent in the first year. All because they went from a punitive model to an ACES- informed model. Here, that very same teacher who would have sent the child to the principal’s office, now stops, pulls the child aside, calms them down and asks the simple question, “Did anything happen last night?”
It was a small alternative high school with less than one hundred students, but they increased the graduation from seven a year, literally the number seven, to fifty.
Antony: Nearly an eighty percent graduation rate for some of their kids. The alternative school is one of the last stops for a lot of these kids, right? That’s its name, the Alternative High School. The success came from using ACES-informed strategy. It also included onsite mental health counseling and an onsite health clinic. But most important, there was a culture change and a lot of training with the teachers, staff and the administration around new approaches to handle kids when they act out. Things like questioning the underlying cause of the misbehavior. Is that person is wired to act out or if there is something else at play?
For the last two and a half years, Empire Health Foundation has been figuring out how to get upstream of a number of critical health concerns. For example, we’re still doing a lot of work on health care access. As a whole, we’ve helped reduce the number of uninsured in Spokane County from 13.1 percent down to less than 3 percent.
Don: That’s fantastic.
Antony: Yes. Nationally, they’re super proud, because the number of uninsured has gone from 17 point something percent, nationally, down to 14 percent! While here in Spokane it’s 3 percent. We also continue to work on the treatment side of things, primarily with bilateral integration between mental and physical health care.
In regard to ACES, we’ve partnered with Spokane Public Schools to do ACES- informed strategy at Rodgers High School. There, they reduced out of school suspension by thirty-five percent in the first year. For a mainstream high school with over a thousand kids, that’s a significant improvement.
When we first looked at ACES, it was about reducing and mitigating ACES for kids. We really wanted to do something that was a systems change, something that would affect the largest possible number of kids in Eastern Washington. We surveyed many sectors. We looked at early learning, juvenile justice, homeless youth, health care, pediatricians, faith-based, you name it. The two sectors that had the most promising changes happening across the whole system were K-12 schools and child welfare.
That’s how our journey began about eighteen months ago on child welfare. It’s because they were implementing differential response, or Family Assessment Response, FAR, and they were implementing Performance Based Contracting, or PBC. Now, we find ourselves not just knee deep or waist deep, but probably at chin level in child welfare. Our overall goal is to reduce the number of kids in out of home placement, in foster care, by fifty percent in five years.
Don: That’s an ambitious goal.
Antony: Yes it is. I’ve actually had people laugh out loud right in front of me when that’s been said. I just smile and I say, “I know it sounds far-fetched, especially if you’ve been jaded by decades of no change in your community, but it’s been done.” For example, it’s been done in Medford, Oregon and Oakland, California, a much larger city than ours and with some of the worst urban blight and disparities for African Americans nationally. Both of them have reduced their number of kids in the system; one by fifty percent in five years and the other by sixty-five percent.
We think we can bring the strategies that they’ve been using in Medford, Oakland, L.A. and other places to Eastern Washington and achieve the same goal. That’s our target, to reduce the number of kids in foster care by fifty percent in five years.
When you think about child welfare, not only do these kids come with ACES that cause Child Protective Services to be called, but the very system itself adds even more ACES. Let me ask you this. What percentage of the inmates in Spokane County jail do you think were former foster care kids?
Don: Forty percent.
Antony: That is so much higher than most people guess, and it’s still too low. It’s sixty percent. We’re basically building a pipeline to our jails. This was written about in a great series of articles by Jody Lawrence-Turner in the Spokesman Review. From October, I think. (Please see attached link to read Jody’s articles).Yes, we are building a pipeline to our jails with our foster care system. But what is the reason? I say that the system itself is adding ACES. Jody has a couple stories in her articles where she has one-on-one interviews with the inmates, and just former foster care folks in general, not just in the jail. Here she is, talking to these multiple convicted offenders, right? They can’t remember how many times they have been in jail or for what reasons, but they can tell you the clothes they were wearing, the toy they dropped, and every other minute detail of the day they were removed from their parents.
I have zero doubt that the day they were removed from their families was as singular an ACE as every other ACE that came before it. What I like about these examples I share from the great work that the Spokesman did or the bear in the woods is that your donor base and the readership of your newsletter, if they understand the larger context of ACES, will have a greater appreciation for organizations like Morning Star Boys’ Ranch. Organizations like yours play a critical role working with the hardest of the hard. You guys are doing …, I’ll use a faith-based metaphor, you’re doing the foot washing. You’re doing the hardest work. And Morning Star knows that the thing that is so powerful about ACES awareness is that it shifts the blame off the child that has been injured. After you get some training in ACES, you can go from, “That kid is a bad seed,” to” That kid has bad behavior, but the root cause is not their fault and I am in a position to help that child.” That’s pretty powerful, right? So, what’s amazing about ACES-informed child care is that we can identify the problems and actually do something about them.
I also think our scientific understanding will continue to grow exponentially. But what’s going to be tough then is, how does it translate into what do we do as a community? I know that what’s super clear is it’s not about single actors. Not just Empire Health Foundation or the school district or Morning Star or anybody. Not just Children’s Administration, right? It will be about the fact that this is a complex dynamic system. These families have crisis, accumulating ACES, and we’re going to reduce them only by a using multi-prong dynamic strategy.
There you have it! Empire Health Foundation and ACES. One hundred thousand to fifty thousand foot level. Hopefully there’s something in there that you can use.
Don: There absolutely is. Thank you very much, Mr. Chiang.