Health

REBROADCAST: Understanding Childhood Trauma – OPB

Dave Miller hosts a panel discussion at The Providence Willamette Falls Community Center.

Dave Miller hosts a panel discussion at The Providence Willamette Falls Community Center.

Sage Van Wing / OPB

In 1998, researchers from the CDC and Kaiser-Permanente put out a groundbreaking study. They catalogued a variety of what they called ACEs. It stands for “Adverse Childhood Experiences.” ACEs included things like sexual or physical abuse, or living in a home with domestic violence or substance abuse.

The researchers found that the more ACEs someone has, the higher the chance of all kinds of negative health outcomes — from heart disease to cancer to mental illness.

Now the public health community is catching up with this cutting-edge science. Pediatricians, social workers and teachers are asking: Since we know just how damaging childhood traumas are, how do we respond to them? And how can we prevent them in the first place?

We spoke with national expert Nadine Burke Harris, author of “The Deepest Well;” RJ Gillespie, pediatrician at The Children’s Clinic; Amy Stoeber, child and adolescent psychologist; Sue Skinner, pediatrician at The Children’s Center; Ellen Baltus, social worker in the North Clackamas school district and Fariborz Pakseresht, Director of Oregon’s Department of Human Services.

The following transcript was created by a computer and edited by a volunteer:

Dave Miller: This is Think Out Loud on OPB and KLCC. I’m Dave Miller. The experiences we have in our childhood, positive and negative, have a huge impact on our later lives. That’s not exactly surprising, but the extent of the connection is breathtaking. It’s only recently become clearer. In 1998, researchers from the CDC and Kaiser Permanente put out a groundbreaking study. They cataloged a variety of what they called ACEs. ACEs stands for ‘Adverse Childhood Experiences.’ ACEs include things like sexual or physical abuse or living in a home with domestic violence or substance abuse. The researchers found that the more ACEs someone has, the higher the chance of all kinds of negative health outcomes, from heart disease to cancer to mental illness. Since that first ACEs study came out, further advances have helped us to understand how this works: that the stress from these experiences actually changes our immune systems and brain chemistry. Now the public health community is catching up with this cutting edge science. Pediatricians and social workers and teachers are asking, ‘Since we know just how damaging childhood trauma is, how do we respond to it, and how can we prevent it in the first place?’ A couple weeks ago I sat down with a panel of local health professionals who are all thinking about these questions in various ways. The occasion was a visit from a national expert. Nadine Burke Harris is the founder and CEO of the Center for Youth Wellness in San Francisco. She is the recipient of a 2016 Heinz Award, the author of the book ‘The Deepest Well’ and the creator of a 2014 TED talk about ACEs that’s been seen almost 4 million times. I asked Dr. Burke Harris if there was a specific child who she had worked with who opened her mind to the impact of childhood trauma.

Nadine Burke Harris: There was a patient that I talk about in ‘The Deepest Well,’ Diego, who was a 7-year-old boy who was brought in to see me by his mom. His teacher had recommended that she take him to his doctor because she thought that he might have ADHD and thought that he might need medication. When I saw him, a few things jumped out at me right away: He was adorable. But he was also itty bitty. He was really little. In fact, when I looked at him I had to double check my chart because, even though he was 7 years old, his height was the 50th percentile, the average, for a 4-year-old. And over the course of doing my physical examination and doing my history and physical – which is what we doctors do – what I discovered was that, in addition to being little and having troubles with his behavior, he also had eczema and it looked like he also had asthma. Traditionally I would have gone about addressing that in the way that I was trained to address it in medical school which is, ‘Okay, I know the treatment for asthma, I know the treatment for eczema, I know the work-up for a kid who seems like they’re not growing very well and I know which forms I’m supposed to give to assess for ADHD, or Attention Deficit Hyperactivity Disorder.’ But the thread that really changed my perspective was the history part of my history and physical. When I asked mom when this child started having his behavior problems, she mentioned that it was really after he had experienced a sexual assault at age 4. Then when my X-ray of his wrist – called a bone age looking at what his skeletal maturity was – that came back and that was also at age 4. I started just asking myself the question: ‘What is going on in this child’s body? Is it possible that these things are related?’

Miller: When you had this major realization, how did your clinical practice change?

Burke Harris: It was completely transformed. I think the most important thing, when we dive through all of the research, the thing that is critical is what all of the research tells us. There’s a lot we still don’t know, but every bit of research tells us that early intervention improves outcomes. Full stop. There’s no debate on that. In order for us to do that, we need to be doing routine screening for ACEs in primary care. So that was the absolute first thing that we started doing was screening our patients for adverse childhood experiences so that we could begin doing that early intervention that we know improves outcomes.

Miller: What is the intervention? What can help a child, contemporaneously, who has been subject to various traumas?

Burke Harris: When we understand the biological mechanism of how adverse childhood experiences leads to toxic stress – this overreaction of our fight or flight response – we can get really detailed in the biochemistry and the physiology of it. But what all the research essentially tells us is – number one – safe, stable and nurturing relationships and environments are healing for kids. Right? That’s pretty simple. The treatment is reducing the dose of adversity and enhancing the ability of the caregivers in that child’s life to be a buffer to the child’s stress. Now, that’s easy to say and, for those of us doing it, it’s hard to do. But we recognize in order to do that, we need to have two-generation interventions. It starts with helping the caregiver recognize their own history of ACEs and understand what’s going on with them, so they can recognize when they have an overactive stress response and how they can make different choices for themselves and for their children.

Miller: This seems like a great time to bring in Dr. RJ Gillespie, a pediatrician at The Children’s Clinic. You created a screening protocol for pediatricians in your practice. When parents bring in their babies for their 4-month-old checkups, can you describe what you and your fellow doctors ask; what you do?

RJ Gillespie: Sure. We started about five years ago with asking the ACE questions to our parents, really with the idea of trying to identify which families might need more support from us in understanding how their trauma might affect their own parenting. Our questionnaire really has a couple of parts: We start with the ACE questions themselves. Then we have a survey that talks about resilience – which really is the antidote, so to speak, to ACEs – and then asking what sort of resources families might be interested in. With that just kind of launch to see what would happen.

Miller: Was it hard to get pediatricians, who maybe didn’t think this is what they were signing up for when they started their residency, to ask these questions?

Gillespie: Initially, yes. The families never really pushed back. The resistance that we see always comes from other providers. I think it’s really coming from a place of concern: that we’re not gonna have time to deal with these issues, that we’re not gonna have the skill set to deal with these issues, or that we’re not going to have the resources that families need. But, that said, the families were very accepting of this process. I think that was one of the first things that really helped to change the minds of the other providers, was really that the families felt like they needed this. I think that many families who have experienced trauma have in the back of their head that they may somehow pass that trauma on to their kids. So it’s a worry that is in the back of their mind that is unspoken. When that unspoken worry is put out on the table, they realize that they now have a partner in their pediatrician, someone who’s going to walk with them through this journey and really help them to figure out how to do better than what was done to them.

Miller: Well, in terms of that partner in the journey, what does happen when… a father, say, in one of the checkups, says ‘yes’ in response to those various ACE questions? That’s what you’re trying to get, but when you get those ‘yes’s’ – or that’s what you’re trying to figure out – what does the doctor do?

Gillespie: Well, first of all, I would say that getting the ‘yes’ is not necessarily my goal.

Miller: Right. Finding an answer to the question is the goal.

Gillespie: My goal actually is to change the culture of practice. The disclosure itself isn’t as important to me as a family getting the message that they can actually talk to me about whatever it is that they have going on in their lives, and I will find a way to help them. So, it’s not about the disclosure for me. It’s about the change in culture, that trauma is actually an issue that I will help them with. I think that most people come to their pediatrician thinking that we tell kids to eat their broccoli and we deal with their ear infection or whatever else. But to actually bring their social history and their past history of trauma into the conversation is new. So for me, the goal of the screening really is to get to that point where people realize that they can have that conversation with me.

Miller: This seems like a really important point. What follows from that? What do you gain when you have that kind of openness of a relationship, if the overall end goal is a child’s health, or a parent’s well-being as well, because those are also related?

Gillespie: Of course. I think the message is that these social pressures and these traumas and things that are going on in people’s lives have more potentially effect on somebody’s health than what’s going on with us giving shots or antibiotics for infections and things like that. If a family is given a set of instructions from me, and this happens all the time now, where I’ll say that the family needs to go to physical therapy and a neurologist and blah blah blah, and then the mom will look at me and say, ‘That’s great, but I need to get food on the table.’ That’s the thing that’s actually preventing that family from good health because, if they’re at that level of need, then they’re not gonna do any of the rest of it. I think that as providers we have this sort of misperception, or preconceived notion, about what we call non-compliance: like the families that don’t follow through on any of our recommendations. What the ACE work has taught me is that none of those preconceived notions are true, that the things that are really barriers for people achieving good health are social things that perhaps have never been talked about in practice before. But if I can address that issue, I have a better chance of getting that kid the other services and the other things that they need.

Miller: Without, obviously, mentioning names, does any patient come to mind, or any family, who you think is a good example of how this new approach is helping people?

Gillespie: Sure. I had a family that, really, the ACE conversation came out a little bit differently than the screening itself. It was a family that came to me with some complaints about the child’s discipline. The bottom line was that the 4-year-old, whenever he was disciplined, [he] giggled, which is not an uncommon reaction for a 4-year-old. But, this mom had a pretty significant trauma history and some social pressures that were going on at the time, so she found that reaction to be extraordinarily aggravating. I could see her, during the visit, tensing up and turning red and her neck muscles were standing out. When I started talking to her about where that reaction might be coming from, in terms of her own history, and really helped her to understand that the child’s reaction was more nerves than disrespect, which I think is how she had interpreted it, we were able to kind of link how her trauma affected how she was disciplining her child. Then at the next visit, which was just a well-visit about six or nine months later, when I asked her how things were going, she said, ‘You know what, I’m falling apart. My mom just died, our food stamp benefits have been cut and I need help.’ Instead of me having to probe for these issues, she knew that it was safe for her to come to me and say these are my real needs. We’ll get to the shots and we’ll get to the conversations about safety and prevention and so forth. But her immediate needs, she was able to just lay out for me without really having to ask. That’s because that culture had changed because I’d had the conversation with her and I’d let her know that my office was a safe place to deal with those things.

Miller: It sounds like, to do the job that you’re describing now, you need to not just be a particular version of a medical doctor, a pediatrician, you also need to at some points be a therapist or a social worker or at least somebody who knows enough about social service agencies to connect your patients with those services. It’s a lot of different things that are on your plate now.

Gillespie: Yes, I think that’s true. We’re really looking at how we deliver services differently to some degree. But, I think that the best medicine in these stories is really the medicine of listening. There have been good studies that look at what makes a person who’s experienced trauma feel like they healed: the Survivor Voices study, for example, that the Trauma Healing Project in Eugene put together. The thing that was most correlated with a trauma survivor feeling like they were healed was having been listened to with compassion. I don’t think that takes a special skill set. It takes intention. That, as a provider, I’m going to sit with that family and listen. I’m gonna put my computer aside if I need to. I’m not going to lean on my training to fix everything, which means that I’m not really paying attention to the conversation. I’m gonna sit with the family and I’m gonna listen. That by itself is a therapeutic intervention that I think people really underestimate the power of.

Miller: How many of the skills, like listening for example, or the others that you’re talking about now, which seem like they form the crux of the clinical tools that you use now, how many of these were actually truly taught and emphasized in your training in med school or in your residency?

Gillespie: [laughs] I could write a book about all the things that I wasn’t trained to do in medical school that I do on a daily basis now. [laughter]

Miller: Would the book essentially be, ‘this is what you really should know if you’re going to do a good job’?

Gillespie: Absolutely. [laughs] Absolutely.

Miller: I mean, we can laugh in the audience, but that’s a serious indictment of American medical training.

Gillespie: I think so. And frankly, it’s been a while since I was in medical school, so things have changed for sure. But, I do think that those basic skills, in terms of listening with compassion and in terms of not leaning on your training to fix everything that’s in front of you, are very teachable. I think it’s innate for some people, which is probably why some of us are the early adopters in this work. But I think it’s very teachable.

Miller: Dr. Amy Stoeber is here as well, child and adolescent psychologist in private practice. I think it’s fair to say that, as a therapist, a lot of what we were just hearing from Dr. Gillespie I assume was drilled into you as, ‘This is the core skill’ of listening to people and giving them space to talk. Is it fair to say that part of what we’re talking about was already built into your professional understanding of what it means to be a therapist?

Amy Stoeber: Absolutely. Part of being a trauma informed provider is shifting the lens of discussion from, ‘What’s the matter with this person?’ to, “What’s going on with you? How can I help and what’s your story?’

Miller: How do you talk about these issues with your young patients? We’ve been focusing a little bit I think so far on parents as a conduit, as a way to help. Especially, you’re not going to talk to a 4-month-old, but you may talk to an 8 or 10-year-old. How much do you talk about, for example, the way hormones are affecting their thinking?

Stoeber: This is the beautiful thing about children. On Tuesday in my office, I had a little boy whose parents are first generation Americans. The narrative of their family is such that the parents both went through extreme amounts of trauma getting to the United States. Dad especially presented with a lot of anger. So I taught these young boys in this family – 5 and 7 years old – the concept of ‘flipping your lid’ which was initially introduced by Dan Siegel: Essentially it’s teaching them about the neurobiology of their brain at 5 and 7. When I was interacting with this little boy on Tuesday, I could see that he was talking about a situation where dad typically would have flipped out but didn’t. I saw his whole body tense up. I said, ‘What happened to you?’ And he said, ‘Dr. Stoeber, I lost my prefrontal cortex.’ [laughter] I said, ‘Where did it go?’ And he said, ‘It flipped.’ I had taught him that brain model at a very young age: that, if you don’t have organization and logical thought, you’re left with that fight or flight response. So even a child at 5 understood that intervention and is beginning to change the pattern of how he responds to trauma in his family.

Miller: Obviously Dr. Gillespie is a Portland area doctor who has gotten this message loud and clear and has embedded a kind of trauma-informed understanding into his practice. How common is that right now among either primary care doctors or pediatricians more particularly?

Stoeber: I think it’s becoming more common. Portland has really embraced the study of ACEs, thanks to both national speakers like Dr. Burke Harris but also people like Dr. Gillespie, who has introduced it to the mainstream pediatricians in the Portland metropolitan area. But it’s been really within the last three to five years. Part of the work I’ve done is to train local pediatricians on what ACEs are, how to become trauma informed and then what do you do? The biggest question I get from pediatricians is, ‘Okay I understand ACEs, this is really important, get it. What the heck do I do now?’ That’s been my work with them is trying to help them build a skill set so they know how to respond when the trauma is presented.

Miller: I imagine that could be the work of many, many weeks or years of someone’s life. But what are the basics that you try to drill into healthcare professionals when they ask that question: ‘How do I actually proceed once we start?’

Stoeber: I think the first thing is similar to what Dr. Burke Harrison and Dr. Gillespie are saying, which is, ask.

Miller: Ask, ask parents, ask patients…

Stoeber: Ask if there’s trauma. If you’re scared to ask, at least go in with the mindset that 64% of all people have at least one ACE and that there are so many people that you’re interacting with on a daily basis that have trauma that their body has absorbed. They’re trying to do their very best to parent kids every day. So the first thing is ask or assume that there is trauma that’s there. The next thing is know that just being – I call it being their present, supportive ‘other’ – this adult in their life, sitting and being willing to hear their story and shifting that lens from, ‘What’s wrong with you?’ to ‘What’s going on, and how can I help? What’s your story?’ That’s the first step. Then giving them some specific tool sets. Really, what we’ve done is we’ve created an entire curriculum of what we call resilience-building initiatives for a group of pediatricians in Portland so that they feel empowered when they walk into an exam room, whether it be a family with ACE scores of seven or a family who’s doing quite well but still will benefit from attunement and attachment.

Miller: Dr. Burke Harris, is there a way for the federal government – if we’re talking about, say, a Medicaid population – does the federal government reimburse for these conversations? Is there a federal code where people could be paid to talk about what you all are agreeing they should be talking about?

Burke Harris: Not yet. I think there are more and more states across the country that are looking at, for example, how to support trauma-informed care through their Medicaid dollars. In fact California is looking at it right now. But it’s not happening yet and certainly not in any widespread way. There is something called EPSDT, Early Prevention something something something. Those are dollars for screening and early intervention, and the question that a lot of states are looking at is how to use those EPSDT dollars to support this framework.

Miller: Dr. Gillespie, would you want this to be reimbursed? Would you want there to be a system that either incentivized these kinds of conversations or required them?

Gillespie: Not as a first step, no. I think there’s too much skill building that needs to happen amongst providers first in order to do it correctly. I would be concerned that there would be a perverse incentive, for example, behind paying for screening, where people would do the screening without the appropriate follow-up conversation, without the presence, just to be able to pull in the funding. I’m sure there are no providers like that listening on the radio right now. [laughter] But that is a concern of mine: that if it’s not done correctly and it’s not done compassionately… that you don’t want to do it just for the money, I guess.

Miller: What’s the harm that you’re imagining? If somebody does this in a kind of rote way, just going through this list asking questions and moving on, what would the effect be, do you think?

Gillespie: I think there’s always concern that having these conversations might be re-triggering for a family that’s experienced trauma and that it might cause harm in that way. I think that, if the conversation is not a natural consequence of a screening tool, then that message of silence tells the family that that conversation isn’t important or that they’re not safe having that conversation in that particular place. And I think that that’s the wrong message to send, obviously. For me, when I do have a disclosure in my practice, I may not talk about other things at that visit other than that disclosure because I think there’s nothing else that’s more important during that time. I’ll come back to the other, counseling and safety and prevention, sort of messages later. But I think you have to be willing to really be present for that conversation and to have that conversation so that you’re not giving the message that the disclosure is not safe.

Miller: Now we’re going to hear from Ellen Baltus. She’s a social worker at Lot Whitcomb Elementary School in the North Clackamas school district. She’s helped to put in place a whole new system at her school based on an understanding of ACEs. I had her describe how her school is different now.

Ellen Baltus: At Lot Whitcomb we have a variety of systems in place to build relationships with kids. It starts with the beginning of the day, where kids used to come in and they’d come in the cafeteria and it was loud and overstimulating. We realized that that was re-triggering kids. So we switched our day to start in the classroom, with breakfast..

Miller: For everybody.

Baltus: For everybody. Our school is 100% free and reduced [price] lunch, so everybody gets the opportunity to have breakfast. Instead of starting their day either missing breakfast, because that’s too overstimulating for them, or starting with an argument with somebody in the cafeteria or something, they can start in the safety of their own classroom. And it starts slow; it doesn’t start immediately with academics, so the teacher can have an opportunity to sit with a child and start building relationships with them. If a teacher knows that a particular child has significant trauma or something, they can start their day greeting them and saying hello to every child that’s coming in, but that particular child might be able to spend a few minutes with them before the formal day starts. Then, depending on what happens and how that child displays behaviors as a result of their trauma… For some children, they move into the fight, flight or freeze response. If it’s a fight response – I’m thinking of a 1st grader that might get upset and knock over chairs or go under a table or something – instead of looking at that child as, “I’ve got to call the office and they have to be disciplined and be suspended or something,” we have pause areas in every classroom. A teacher has been trained on trauma and would be able to begin identifying signals for what that might look like. [For] each child, they might be able to understand what those behaviors may be – like maybe the child starts pushing things first – and be looking for those. Then [they] might prompt the child, say, ‘Honey, do you need a break? Do you need to go in the pause area or take a fidget?’ or give a putty or something like that, and maybe that would help that child regulate; then find an opportunity to find me or another person that child has a close relationship [with] to maybe have a conversation to find out what more is going on, if they didn’t have the time to do that.

Miller: You have something called the Wolf Den as well. What’s that?

Baltus: And then we have the Wolf Den because we’re the Whitcomb Wolves and my principal, Cathy Lehman, helped to initiate that a couple of years ago. If the pause area still isn’t effective for kids and they can’t regulate in that space or the space for some reason or another is too triggering, they can get a break in the Wolf Den and that’s staffed all day with people and it’s not seen as a time out.

Miller: It’s not the vice principal’s office?

Baltus:  No, but we do have that as well. It’s the regulation center. And so kids can go there and there are people there that will hold spaces. What I call it would be listeners who are trained and aware of trauma responses. Or maybe the child just needs different sensory items, puzzles, drawing options, headphones with music, yoga, a tent that they can hide in, a couch or blankets and there are adults there that will listen to their story. And what we found is that allowing a child to go there for say 10 minutes (we have a timer) helps their body to naturally regulate.  When you’re in fight, flight or freeze mode, if you can get to a place where you feel safe, your body will naturally begin regulating.  And so the Wolf Den is a safe place where kids can run or get out of their environment and they’ll regulate and then they can return to class and get back like you were talking about their prefrontal cortex. All the kids in our school are trained about brain science and what the amygdala and the prefrontal cortex are.

Miller: You teach 1st and 2nd graders about amygdala?

Baltus: So they’ll say Mrs, B., “my amygdala is really active” [laughter]  when they’re five.They can do it and they do it and they know the flip the lid thing and in the whole school, so everybody is speaking the same language and they learn about zones of regulation, where the green zone is the learning zone and that all of us go in and out of regulations, all of us, adults and teachers, too. And frankly that’s one of the biggest things we’ve done at Whitcomb. Doctors aren’t trained, teachers aren’t trained about trauma and how to respond to trauma and vicarious trauma when they are going to school to learn to be a teacher, they don’t learn about sexual abuse, physical abuse, domestic violence, suicide. And when a child comes in, who’s five and helpless, and tells them that they were sexually abused the night before or physical abuse, it begins to wear on a teacher and they need an opportunity to  get some support for that. So we do that. That’s one of the biggest things we do at Whitcomb. We have myself, a social worker, and another social worker meet with teachers individually every other week to kind of debrief some of those situations and look at their own self care. What are they doing to not take this on? Are they getting enough sleep, getting enough exercise, all those sorts of things and what’s their plan? And we don’t judge them for that. If they’re feeling like they need a break, we’ll go cover their class for a minute in order to take care of themselves because dysregulated adults can’t take care of dysregulated children.

Miller: What you’re describing seems to me to be an entirely revamped school. How did you get by?

Baltus: We’re great, we’re the same.

Miller: But how did you, you’re a social worker, how did you get the principal Vice principal. All the teachers buy into all of this?

Baltus: Once people hear the truth, I was lucky to have an administrator who was willing to let me train all the staff on the ACEs and the impact of trauma on the brain. And there’s so much research out there, there’s so much knowledge that once people hear that information then they realize, oh that makes sense and how to respond and that kid’s behaviors, they’re not trying to be manipulative, they’re not trying to intentionally hurt you or other people. It’s just that they are lagging the skills needed for the demands that were making on them. And that there’s all this resilience research that shows that if you have a primary caretaker can buffer some of those responses. And if you teach them regulation skills, which we also do on how to regulate and you look at them beyond just academics, the whole child, their competence, you will see a change and we’ve seen it. And so once they learn that information and they begin implementing it, they see that while this child did calm down in 10 minutes because I didn’t re-trigger them and how to come at them slow and low. So you come at them as a non-threat, watch your facials, watch your tone of voice, watch your rate of speech, and sometimes go down.

Miller:  You’re calling me down right now.

Baltus: Right. And we have a group meditation for teachers once a week. Our principal found a way to get Headspace, which is a phone meditation app, to give to all our staff for free a year. And teachers begin exploring that and we share that with our families sometimes. And they begin exploring it and found that meditation and mindfulness were what he’s talking about. It’s so exciting to hear him just say, being present. So many people with all the phones and technology don’t know how to do that. Just to be right here, right now without judgment, it changes everything.

Miller: I want to bring another voice here in our panel. Dr. Sue Skinner is a pediatrician at the Children’s Center, it’s a child abuse intervention center in Oregon City. Can you describe what it means to be a pediatrician at a child abuse intervention center?

Sue Skinner:  We see kids where there’s a worry of abuse or neglect. So the majority of kids get referred to us by child protection or law enforcement.

So a child or a family has come to the attention of the system and that’s where the referral comes, but really referrals can come from anywhere. So it might be a therapist, it might be a parent that calls up and says, hey, this is what my kids said, what should I do? Another doctor might refer him from primary care and schools. So they come from a variety of situations. Probably the most beautiful thing we do is that we spend a lot of time with them, which is something that is in primary care–I was a general pediatrician many moons ago and I’ve been doing this work in child abuse clinics for about 23 years–is that we get to listen, we get to be authentic and we get to spend time. So that’s probably the best gift actually. But we work in teams of three. We have a medical provider which is a pediatrician or a nurse practitioner. We have a forensic interviewer who can really spend the time talking with the child. And while myself and the interviewer are seeing the child, we have a master’s level therapist, a family support person that’s actually spending time with the parent or caretaker, taking care of them. Because screening for ACEs is not just the child and it’s not just the caretaker, it’s both.

Miller: How do you talk about the things you need to talk about without re-traumatizing your patients?

Skinner: We get that question a lot actually because people will think coming in is going to do exactly that and I would say it’s totally the opposite when you don’t talk about a problem. It doesn’t go away. It’s still there and it just festers. And so   it’s just RJ said, Nadine said, I think everybody said just be real, slow down, take the time.  And just listen, that’s the first step before asking: What support systems do we have? Where do we need to refer you to? Do you need a counseling detective?  Whatever it is, just listening actually is the opposite of traumatizing, it’s validating their life because what happened to them doesn’t go away because I’m too anxious to talk about it.

Miller: How often do you find that what you’re doing, listening and giving these young people a chance to have their stories heard, that they’ve never had that before?

Skinner: That happens a lot. The one that surprises me the most and one thing that’s hard for us to ask about is depression, self harm, and suicide. A child might be referred for a worry of abuse or neglect, but we always ask about everything. So if they’re referred for sex abuse, we ask questions about physical abuse questions about neglect, exposure to domestic violence, gun safety. We ask a variety of questions, but we asked some mental health questions too, and we’ll ask about depression, self harm, and suicide. And sometimes how do you frame a suicide question when a kid’s been referred for something totally different, but you’re still trying to ask about it? That’s the one that surprises me the most is a teenager that has a pretty reasonable social circle, that has two parents home that they have a pretty reasonable relationship with and maybe they’re even in counseling and they’ll say nobody’s ever asked him that question before which is just a reminder that just RJ said, we just need to ask.

Miller: It strikes me that you have the unusual role among folks on this panel, that it’s been your job, even though you’re a medical doctor, you’ve been doing for, it seems like your whole career, you’ve been asking the kinds of questions that only now are becoming ever so slightly more standard in some places that have gotten this religion. What’s it like for you to see the things you’ve been doing for your whole career, finally take root among other professionals?

Skinner: I remember when this study came out because I had been doing this work for a couple of years and I remember when it first came out, it was like, oh yeah, that makes sense. We kind of knew that, but now it’s on paper, I think what it’s done is that it improves partnerships amongst professionals because for people that work in a child abuse clinic or professionals that maybe aren’t doctors or interviewers, but work with a child abuse clinic, it’s kind of its own little world. We can do a really, really good job with what we do, whether it’s case investigation or child protection safety in the home or our assessments that we do. We can do a really good job except for the passing of the baton between systems. So when I see a family and I spend a half day with them and I do a great assessment and listen to parents, listen to the kid and write a great report, how well do I pass them back to RJ who is their primary care doc? Not so well. So by increasing his awareness at his clinic and by me recognizing that other systems get it now, too, what I’ve gotten in my own little world, it makes that hand off a lot easier, a lot smoother. And then when RJ gets the kid, he says, oh my gosh, I don’t know what to do with this. He’s like, yeah, I got this, thanks for doing the assessment. We can take it from here. So I think just the overall care improves and then the trauma to families improves because they don’t have to go back to primary care and think, oh, I can’t talk about this stuff with my primary care doctor. It’s like second nature.

Miller:  I saw a lot of you nodding your heads when Ellen Baltus mentioned the vicarious trauma that caseworkers or pediatricians or social workers may be exposed to. Is that something that you think about?

Gillespie: I think it’s something that just needs to be a part of the culture of health care that we focus not only on improving costs and improving care and improving outcomes, but also taking care of the workforce. And I think one of the things that I’ve seen is that many systems will start looking at self care as one of the outcomes that they want to see in their office, but please do that at 5:30 when you punch out as opposed to something that we do in the office every day.  And to me it’s a really important part of being able to do this work and to do it meaningfully, to be able to take care of yourself and to really be able to empty out some of these stories that we hear. We’re expected to be a vessel for the conversation but we have to be able to empty ourselves out and really  process those conversations and move on from them.

Stoeber: And what I would add to that is that when I’m working with pediatricians, before we even do any resilience building intervention, we do what’s called trauma-informed care for the entire office because the entire system has to be trauma-informed, the entire system that that family is going to interact with because they don’t just interact with their pediatrician. They interact with the front office staff, they interact with the nurse manager or the medical assistant, they interact with building people. All of those people when their trauma-informed will raise that child and that family up and better understand them which will decrease everybody’s vicarious traumatization.

Miller: Dr. Fariborz Pakseresht is with us as well, Director of Oregon Department of Human Services since September of 2017.  Before you took over at DHS you were the head of the Oregon Youth Authority for about 5.5 years. That’s the agency that manages juveniles who are caught up in the justice system. I imagine that these were young people who almost by definition had had some kind of childhood traumas before they got into the system that you were in charge of. How much did you consider minimizing more trauma as you were to a great extent in charge of these young people?

Dr. Fariborz Pakseresht: Generally in correctional systems and unfortunately the correctional systems in the US are different from other places in the world, but a reaction generally to aggression is aggression. And in fact, we realized over time that just touching a youth can inflict trauma, so an individualized approach becomes so important. In fact, there’s a great experiment that we had in Oregon Youth Authority and Dr. Gillespie talked about a culture which we quite often talk about. Our biggest challenge was changing our perspective from a quote “correctional culture” to a “developmental culture.” That does not mean that accountability doesn’t exist, but that culture actually begins with safety and safety is the most important for all of us, safety and well being and what we build on that. And we started this for our children that we were in care of in Oregon Youth Authority and then we extended that to staff.

Miller: If we are talking about what is effectively a jail or a prison for young people, if you say the overall mindset, what’s shaping this place is not corrections but developmentally helping somehow, what does that mean in practice? Because they’re still locked up?

Pakseresht: Yeah, they are. But I’ll tell you you can live in a palace and be imprisoned and you can live in a correctional facility and be the most enlightened human being. I’ve seen that. Because when these kids come into the system as tough as they look, as tough as they act, what they’re really missing is a sense of connection, self respect, self worth. What most of us are missing is time. If any of you have time, I’ll buy it, I’ll pay a big price for it and what you have when you are incarcerated, all you have is time. And if that time is spent in contemplation, meditation, in fact we are now offering meditation classes then you can really begin to connect with the source of internal power which replaces that sense of false power, carrying a gun or being tough because that sense of internal connection to that power can help you overcome any adversity in life. So if we have a collective vision of that healthy individual that we want to turn into society as an adult, then I think we all agree that we want that person to be healthy, we want them to be crime free, we want them not to be on public assistance, not depressed, have enough education to support themselves and their family and most importantly live a life of purpose and be happy. So if that’s our mindset then every step that we take should be aligned with that outcome. So then hitting a kid over the head is not necessarily the best next step to get them to that place even though that kid might be coming at you with aggression. So accountability can be put in place after safety and a caring relationship is in place and then you really begin to see engagement, engagement by kids, engagement by staff, and that leads to building a community and the lack of a community is what has brought us to this place, both in correctional facilities, youth correctional facilities and really in the broader community. So what happened is that we actually did a bit of deep dive into the data because we had an issue with isolation.  When a kid misbehaved, hit, assaulted, did other things, we would put them in isolation. Well, science knows, studies show that that is significantly harmful to youth. When we actually dug deep down into this data, we realized that these kids that were experiencing the most instances of isolation were not the most aggressive and there are very few kids that are really criminally-minded, but they didn’t have that mindset. In fact they had come into the system with significant trauma, 100% of them were on psychotropic medications, LGBTQ kids, kids that actually could not regulate their emotions. They did not have the skill set that they needed in order to know how to communicate. So we were forced to create a program that focused on emotional regulation, trauma-informed care, skill building and giving these kids a community that they could feel that they belong to and then actually try to transition them back to the community within 60-90 days. Within eight months we had a 77% reduction in fights, and 84% reduction in isolation. That is the impact of dealing with kids like human beings in a trauma-informed way.  [applause] And I want just to build very briefly on what Dr. Skinner mentioned as part of the challenge and she actually stated it beautifully. One of the biggest challenges that we face is that many of us do great jobs in our own silos, but there are so many systems that touch children as they emerge from being a child to being an adult. And again, the analogy is if you actually treat this thing like a relay race where if we drop the baton, we lose the race. I could have this beautiful plant that I have cared for and then I give it to my neighbor and there’s no watering for a month, that plant dies. So we can do great work in our own systems. But if we cannot come together and really think about that next best step to get that kid that we want, for our own kids, to become a healthy and productive adult, we’re not going to get.

Miller: How are you going to apply everything you just talked about and everything we’ve heard for the last hour plus to an even bigger job now, the Department of Human Services?

Pakseresht: We’re gonna do it one step at a time. In fact, one of the major feeders into the juvenile justice system is the foster care system. I’m moving my way upstream to figure out exactly where the problem is. What we’re doing naturally is that every caseworker that we hire watches Dr. Burke Harris’ video. We have actually two full days of trauma-informed care training that happens over the course of 12 months. And one of the first modules of that training is how you take care of yourself. But let me just be very transparent: we can do the best training that we can, we can do all of these learnings but when a caseworker is so stressed, when she or he is carrying five times more cases than they actually can, none of this stuff works. So right now our focus is on reducing casework and case load. The Oregon foster care system is 1.5 times the size of any comparative system nationally. And we should be able to share something with you all within the next few months because we are just taking too many kids out of homes. We need to have a better approach around putting resources in home with parents.

Miller: I’m not sure. I mean we’ve been talking a lot on Think Out Loud about Oregon’s foster care system for a few months now, I don’t remember hearing the head of DHS say that exact exact sentence that we take too many kids out of homes.

Pakseresht: You just heard me say that. [applause]. So there is an inflow to the foster care system and then we take care of the kids and then there’s an outflow. There are too many kids coming in, they are staying too long and there are not enough emerging from the system. So we have to reduce the inflow and we have to reduce the length of stay and try to either reunite kids with their parents or put them in a safe and healthy place so that they can grow into adulthood. So that is our focus right now. We are going to be focusing on doing the best that we can to keep kids with their families, not compromise on safety, but also manage kids out of the system. And reducing the size of the system actually reduces the workload, which then leads to caseworkers having enough time to spend with their children.

Miller: Dr. Burke Harris, you have an epilogue to your book that is really hopeful. It imagines the year 2040. Can you describe your vision for what it is 20 plus years from now?

Harris: It starts with me having lots of grandkids. [laughter] But a couple of things that I envision. One is that our educational system has a form that every kindergartner needs to have signed by their doctor in order for them to enroll in kindergarten. It says they’ve gotten their immunizations and they had their TB test and they’ve had a physical and that there’s also just a little check box that says they’ve had an ACE screening and it doesn’t have to say what the score was. It just is an indication that some medical professional has screened this child for ACEs and that is a prerequisite for kids to be able to enroll in kindergarten. And of course that’s easy to do because every pediatrician in America is screening for ACEs because we’ve all been trained on how to do this in a trauma-informed way and how to respond. And as a result, what we’re able to see when we do this early detection and early intervention is that by the next generation we have seen a 40% decline in the number of individuals who have one or more ACEs. And we’ve seen a 60% decline in the number of individuals who have four or more ACEs. And as a result of all this money that we’re saving, we’re able to invest in early childhood care and education among other important national priorities. But the big picture- and hopefully by that time as well, our treatments, interventions and our focus are on trauma-informed care. But in addition, we truly are advancing the medical treatment of toxic stress so that even for those individuals who do unfortunately have a high ACE score, that we’re actually able to prevent some of the long term health and behavioral health consequences that result from a dysregulation of the stress response. So that’s it. That’s the dream. I could go on.

Miller: No, that’s a big enough dream. I thought we could just go down the panel and have each one of you just briefly give us advice for people who are in your position, for example, Dr. Fariborz Pakseresht, in other states or everybody else,in some other version of your jobs, advice for those people for how to get to what Dr. Burke Harris just outlined.

Pakseresht: I was in Oregon City just last month and they told me to talk to a foster child who had written to the president and to the governor. And I walked in that room expecting a teenager. He was a 10 year old and he spoke so eloquently that he could be teaching Toastmasters. And I said, where did you learn how to speak like that? He said he was born like that. I said, give me three things I can take to the people I talk with that we can improve outcomes for kids. He said this. First of all, listen to kids, number one. Number two, he said, when you come to take us from our homes, don’t come at nighttime, the flashing lights scare us. This is a kid, a 10 year old kid. And third he said, when attorneys or representatives in court have them use our words, not theirs. This is insight from a 10 year old. [applause]

Miller:  Ellen Baltus.

Baltus: I think my dream is that we will all realize that we all have ACEs. It isn’t just the most vulnerable populations. Sometimes I feel like that’s where we go, but also that everyone will have the language, little kids will know the language of the brain science. And that they’ll understand how to regulate and have the words that I need to do my breathing now or I need to understand what’s happening in my body and so will their parents. And that they’ll be regular experiences at home where people say let’s do our meditation for today to help build that attachment with kids. And that schools will have that language and will just be part of the regular curriculum and that they will be safe places for kids and they’ll be predictable and routine and kids will see schools, just another place that they feel safe.

Miller: Dr. Gillespie.

Gillespie: I think for me, what I’d like to see is that there’s enough public awareness and enough reduction in the stigma around trauma that a family would come to me and say, when are we going to talk about my ACE score? That, I think that it’s a two sided relationship, right? Like what I do in terms of screening and assessment is one thing, but when a family comes to me, ready for the conversation as well, that would tell me that we’ve moved a long way in this field and that the families are prepared for the conversation and really willing to engage in it.

Miller: Dr. Stoeber.

Stoeber: Children are in systems. So I would want two things to happen. One, the assumption that parents do well when they can and that if they’re not doing well, there is something that we need to understand better. And then that every child in the system in which they interact, whether that be physicians, schools, corrections, et cetera, that every single person interaction with, interacts with a child’s life is trauma-informed and resilience trained.

Miller:  Dr. Skinner.

Skinner: Just that I don’t have a place to work at. [laughter & applause].

Miller: Thank you so much, All of you. Thanks to Tom Soma at the Children’s Center for helping us organize this conversation and thanks to you very much for tuning in.


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