PORTLAND – R.J. Gillespie, M.D., and his team are working with parents at The Children’s Clinic to interrupt the cycle of adverse childhood experiences. Health System Transformation (HST) makes this project possible – and makes preventive and lifelong health priorities, by doing things differently and promoting local innovation.
It’s part of the Oregon Pediatric Improvement Partnership sponsored by Health Share of Oregon, a coordinated care organization serving Oregon Health Plan members in the Portland Metro Area. Gillespie, a pediatrician and health professions educator, is one of the OHA’s Clinical Innovation Fellows for 2015-2016.
Adverse childhood experiences are often referred to as ACEs. It is a relatively new term for stressful events that can affect a person’s lifelong health and wellness. Statewide, about 35 percent of adult Medicaid members have had adverse childhood experiences, compared to about 23 percent of non-Medicaid adults.
“They are events that make a child feel unsafe, unsupported, or unloved,” Gillespie says. “They can affect that child’s health and mental health in dozens of different ways, including increased risk of heart disease, obesity, lung disease, smoking, substance abuse, sexually transmitted infections, autoimmune diseases, and some types of cancer.”
The most common ACEs are physical, emotional, and sexual abuse, physical and emotional neglect, loss of a parent, household mental illness, household substance abuse, witnessing domestic violence, and parental incarceration.
A person who suffers from these stresses in childhood, in addition to being at risk of physical ailments, is more likely to perpetuate the ACEs cycle.
“Transmission from one generation to the next is not necessarily linear, and may manifest in different ways” Gillespie says. “For example, a person who was physically abused may not become an abuser themselves, but they may experience depression or substance abuse. These things can be helped and treated once they are identified.”
One of The Children’s Clinic’s tools is to provide “anticipatory guidance” to parents at each well-child visit. They talk to the parent about what kinds of issues they can expect to face with their child between now and their next visit, and involve the parent in planning how to respond.
They also teach parents about self-care.
“As a young parent, it’s easy to forget to take care of yourself; instead most parents end up focusing all their energy on taking care of the child,” Gillespie says. “We use the analogy from the airplane: put your own oxygen mask on before helping others.”
The idea is to help parents begin to make connections between their past and their current parenting practices, and then to take “a different path than the one that their parents may have put them on,” he says. "The first step is bringing awareness ... and then to support parents as they explore how they can do a different (and hopefully better) job in parenting their children.”
At an infant’s 4-month screening, the clinician will ask the parent to take an ACEs survey. Those that identify ACEs in their own lives – about 13 percent of those who take the survey – are asked what resources they think would be helpful to their family (classes, support groups, websites, etc.).
One young mother who identified adverse events in her own childhood told Gillespie that she saw her alcohol-abusing father physically and emotionally abuse her mother and sister many times. Now she’s seeing her grown sister suffering the same kind of abuse from her partner.
“She was witnessing the cycle of violence repeating itself in her sister’s household,” Gillespie says. “Her comment to me was, ‘I don’t want to make the same mistakes again. I want better for my children than what I had.’ ”
That kind of intervention is what pediatric care should be about, he says.
“I think what I’ve learned from the ACE study is that we can’t continue to “medicalize” health – that we have to take a hard look at the environment that a child is growing and developing in, and if we have any chance of changing the future health of our patients, improving this environment by being proactive integrating physical and behavioral health. It has to be a part of our work.”
HST is focused on prevention and lifelong health. Through innovation at the local level, innovation is spread throughout Oregon and beyond.
It’s one example of the kind of innovation that is driving the triple aim of better health, better care and lower costs. Through Oregon’s health system transformation waiver with the Centers for Medicare and Medicaid Services, Medicaid funds can be spent on non-medical services like anticipatory guidance, improving the quality of care – and trauma-affected lives – in the future.
