A report from the Grantmakers In Health (GIH) annual meeting, which was held in March in Atlanta.
Nadine Burke Harris, founder and CEO of the Center for Youth Wellness, in San Francisco, was among the plenary speakers at this year’s GIH meeting.
Wendy Wolf, president of the Maine Health Access Foundation, a GIH board member, and a pediatrician, provided a warm welcome and introduction to Burke Harris.
Also a pediatrician, Burke Harris was an energetic speaker, obviously enthusiastic about her work. Her topic was “Adverse Childhood Experiences: The Role of Philanthropy.”
The Center for Youth Wellness’s mission is to urge parents, policy makers, and practitioners to prevent children’s exposure to toxic stress; heal children who have been exposed; and screen children for toxic stress and train others to do so.
Burke Harris’s bio prepared for GIH noted that she “has earned international attention for her innovative approach to addressing adverse childhood experiences [in children] as a risk factor for adult diseases,” including heart disease and cancer. Her work has shown the need to reassess the relationship among poverty, child development, and health, and “how the practical applications of the Adverse Childhood Experiences [ACEs] study can improve health outcomes.”
Burke Harris maintains a clinical practice at California Pacific Medical Center’s Bayview Child Health Center, where she was the founding physician. Bayview Hunters Point is an area of San Francisco where violence is the leading cause of early mortality. (A Center for Youth Wellness staffer subsequently told me that Bayview also has the highest rate of childhood asthma hospitalizations of any area in the city.) And the community is medically underserved—pediatricians were in short supply when Bayview Child Health Center opened, Burke Harris explained.
After conducting thorough patient histories and physical exams of some children at Bayview, Burke Harris found that for most of the kids who were originally thought to have attention deficit hyperactivity disorder (ADHD) she was not able to make that diagnosis. Rather, she found that most had been exposed to some “terrible trauma,” she noted.
So now Burke Harris bases her tool to screen for toxic stress upon findings from the Adverse Childhood Experiences (ACEs) Study, which was conducted by researchers Vincent Felitti of Kaiser San Diego and Robert Anda with the Centers for Disease Control and Prevention. Felitti and Anda conducted this study on a mostly Caucasian, mostly college-educated, adult population. Even in this population, they found that many respondents had experienced at least one ACE—abuse, neglect, or household dysfunction. And 12.6 percent of respondents had four or more ACEs. There was a “dose-response relationship” between these events during childhood and bad health outcomes.
During an ACE screening, parents are asked whether their child has been exposed to, for example, abuse in the home or divorce of parents. The screening is done “simply by asking,” Burke Harris said. Felitti’s research found that an adult with a score of four or more ACEs is at risk of certain conditions—for example, he or she is two and a half times as likely to have chronic obstructive pulmonary disease (COPD), compared with someone having no ACEs, and four and a half times more likely to have depression, compared with a person having zero ACEs.
Burke Harris’s own research at Bayview Child Health Center (published in the journal Child Abuse and Neglect) found that 67 percent of the kids seen in Bayview Child Health Center’s first two years had experienced at least one adverse experience; 12 percent had had four or more ACEs. Also, she found that children with four or more ACEs were 32.6 times more likely to have learning or behavior problems at school when compared with kids with no ACEs. Her work also showed that children at Bayview with such a score “were twice as likely to be overweight or obese” compared with children with an ACE score of zero.
Burke Harris explained in detail that certain parts of the brain are affected by ACEs. The effects of these experiences are “pervasive and long-lasting,” she said. She paraphrased the words of Robert Block, past president of the American Academy of Pediatrics: “Adverse childhood experiences are the single greatest unaddressed public health threat” that we face in the United States today.
But the good news is that “early intervention improves outcomes,” she reported.
What Can Philanthropy Do?
“Philanthropic investment is necessary to get proof” of this toxic stress concept, so as to achieve policy change and a change in medical practice, Burke Harris said. The goal is to raise national awareness about toxic stress, to advocate for universal screening that uses ACE scoring, and “to develop effective interventions and document improvement in long-term health outcomes,” as well as the cost savings from them. In fact, she would like to see a public health movement get started to address toxic stress.
Burke Harris pointed to other areas that also need grant funding, such as “community-based participatory research,” so communities can be part of the solution; both basic science and translational research to develop best practices; data collection and analysis; and two-generation (parents and children) approaches (as the Aspen Institute has advocated doing).
Burke Harris cautioned this audience of foundation staffers that some grant-funded projects to prevent ACEs are “not going to bear fruit” immediately.
What Have Foundations Already Funded on ACEs?
A Pritzker family member’s foundation funded a documentary by Jamie Redford (son of Robert!) on ACEs and their effects. And the Robert Wood Johnson Foundation held a National Summit on Adverse Childhood Experiences in May 2013 and has invested in the ACEs Connection Network, which is an online community. The Annie E. Casey Foundation, a national funder focused on children, is providing funding to the Center for Youth Wellness to validate its ACE clinical screening tool to be used in primary care, so it can then be shared with others.
In addition, the JPB Foundation has awarded a planning grant for the center and Harvard University to determine the feasibility of starting up a national (basic science and clinical) research consortium on toxic stress. The goal is to figure out how to develop “treatment protocols for toxic stress [for use] in primary care.” And the Mid-Iowa Health Foundation in partnership with others funded a statewide ACEs summit and statewide data collection on ACEs in the Hawkeye State.
Questions from the audience
Burke Harris’s responses during the Q & A shed further light on toxic stress. She explained that a primary care physician can do ACE screening during a well-child check-up. Many kids do not have access to mental health care, she noted. Also, families find it easier to speak with their primary care physician, with whom they may have a long relationship. The screening should be done routinely for everyone and can last five minutes or less.
At Bayview, for example, if the screening shows that a child is experiencing problems, he or she is then referred elsewhere within the Center for Youth Wellness for assistance.
Data are important, because through them, policy makers and others can see what governments and other entities are spending on not treating toxic stress conditions. Collecting and disseminating data perhaps should be the first step, Burke Harris explained, before advocating for universal screening for ACEs.
One audience member commented that the health care system is not good about reimbursing doctors for talking to patients, let alone going out into the community to address “upstream” factors leading to adverse experiences. Burke Harris said that the Affordable Care Act is giving the country “the opportunity to re-think our health care delivery and re-think our systems.” ACE screening could prevent “downstream” health problems and reduce the costs of care.
Judith Myers of the Children’s Fund of Connecticut asked how we can have broader conversations about social determinants of health. Interestingly, Burke Harris responded that she is “in a slightly different camp,” because she does not focus on social determinants. Items classified as social determinants go into the category of “discretionary funding,” she maintained, whereas when one talks about an actual health issue, the nation seems to take that more seriously and allocate more funding to it. (So, she said, toxic stress should be described as a health issue.) Thus, she wants to reach people concerned about the costs of chronic diseases because work on prevention of toxic stress and ACEs might actually get funded that way.
PowerPoints from Burke Harris’s presentation: http://www.gih.org/files/FileDownloads/Burke%20Harris%20GIH%20Plenary_March%206%2C%202014.pdf
“The Poverty Clinic: Can a Stressful Childhood Make You a Sick Adult?” by Paul Tough, New Yorker, March 21, 2011 (free access for subscribers). The author discusses Nadine Burke Harris’s work.
Links to information from a few foundations that are addressing this topic:
The Bingham Program, Augusta, Maine: http://www.binghamprogram.org/Pages/index. Note that this foundation supports projects that will benefit the people of Maine, especially those in rural, isolated areas of the state.
Empire Health Foundation, Spokane, Washington, http://www.empirehealthfoundation.org/aces. Note that this funder only awards grants in seven counties of eastern Washington state.
Robert Wood Johnson Foundation (RWJF): Read a March 20 RWJF blog post by Jane Isaacs Lowe about the RWJF’s funding of the Head Start Trauma Smart model at a children’s center in Missouri.