Resilience and Mutual Accountability at the CPS annual conference

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Kirsten Patrick is Deputy Editor at CMAJ. She is currently attending the Canadian Paediatric Society annual meeting in Charlottetown, PEI

 

Much as I love the Harry Potter books and love reading them to my kids, they’re a little too fictional for my taste, and I’m not talking about the magic. Thing is… kids who grow up with the chronic stress of abuse and near-starvation in their formative years seldom – actually pretty much never - go on to be high-functioning, top-of-their-class children with great self-restraint and a well-functioning moral compass. If you heap adversity on a child you’re more likely to get a Neville Longbottom / Tom Riddle mix, not our beloved Harry. So there’s something about me that feels awkward about feeding the Harry Potter fiction to my kids.

This was reinforced for me yesterday when I attended the first Canadian screening of the Sundance Festival film “Resilience” at the Canadian Paediatric Society Conference (brought to CPS delegates by the Palix Foundation and Alberta Family Wellness). Resilience - produced by the Redford Center, “a film production non-profit that translates complex environmental challenges into human stories that inspire” – showcases the work of Dr Vincent Felitti and Dr Robert Anda who designed and conducted the seminal Adverse Childhood Experiences (ACEs) Study for the CDC using a cohort of Kaiser Permanente patients in the late 1990s. The ACEs study derived the ‘ACE score’ (a count of ACEs) and spawned a great many studies that examined the relationship between ACEs and a number of adult diseases, risk factors for disease and socio-economic outcomes as well as early mortality. Resilience features some of the key people who have taken the ACEs study findings and run with them.

Dr Nadine Burke Harris, then a paediatrician in the Bayview area of San Francisco where there is high exposure of kids to community violence, read the Felitti and Anda study and thought, yes, this tallies with what I am seeing with the kids in my practice…they are acting out at school and I’m being asked to treat them for ADHD. “If the ACE study results show this for white middle class people covered by Kaiser, what does it mean for the community I serve?...We are trying to treat a behavior (e.g. with stimulants) but we are not getting to the root of the behavior, which is adverse childhood experiences that are affecting the development of the brain.”  Dr Burke started to screen all her patients for ACEs and to advocate for universal screening.

Okay, I hear the alarm bells going off in your brains….it’s the widely accepted rule of screening, right? "Don’t screen for what you can’t treat…." And as a physician, in an office consultation, we cannot go and fix the family situation or the community violence for the child right there, so what’s the point? But in the film, there’s an analogy that is striking – if we find that a child has lead poisoning because of the water in his/her home we are being negligent if we send the child back into that environment without doing something to remove the cause. Burke Harris has shown how screening can be useful to drive advocacy. She screened….and she found high ACEs scores in the kids she saw – and, unsurprisingly, in their parents – and she did something. As the bio on her recent TED talk states, she founded the Center for Youth Wellness at the California Pacific Medical Center Bayview Child Health Center that seeks to create a clinical model that recognizes and effectively treats toxic stress in children. Her work pushes the health establishment to reexamine its relationship to social risk factors, and advocates for medical interventions to counteract the damaging impact of stress. You can also read about it in a 2011 article in The New Yorker.

And it’s not just California and Dr Burke Harris…other groups have taken the initiative to address as routine these difficult upstream determinants of health. The film Resilience also profiles The Washington State Essentials for Childhood (EfC) vision, which represents the work of health advocates, community leaders, academics and civil society groups working together to actually  provide the resources for children and families to overcome adversity and the drivers of adversity. And it is not just education. Promoting resilience is hard work; it’s not about a brief educational intervention in a consultation –“So, Parent, the IPV that you are experiencing on a daily basis is harming your child’s brain…” - or about writing a prescription; it takes community-wide coordinated effort to change the way kids experience their childhoods.

Also featured in the film is Dr Jack Shonkoff of the Harvard Center on the Developing Child who said that traditionally we have expected people who have had adverse childhood experiences to just ‘suck it up’. He points out that we don’t tell people with cancer to ‘suck it up’; we research the hell out of it and bend over backwards to treat it. Shonkoff coined the phrase ‘toxic stress’ - a chronic activation of stress response not countered by any buffer or support. “When you are a baby and a toddler you can’t 'pull yourself up by your bootstraps',” he points out. The Center promotes the concept of the ‘learning community’ is part of a team that supports a dynamic learning community of Saving Brains innovators to help them advance the impact and scale of their work in countries around the world. Seems to me it’s about embracing the concept of “Health in All Policies” (WHO commission on social determinants of health).

Later in the day, at the conference opening ceremony, the keynote was given by Wab Kinew who discussed the Mediwin principle of ‘Everything is Medicine’, which considers that food, relationships and environment are all part of medicine and wellbeing. Kinew was profiled in a CMAJBlog in 2014. In his talk at last night’s opening ceremony, Kinew cautioned against our tendency to conflate traditional indigenous culture with the culture of poverty, and then pathologise indigenous culture (when it can actually be useful in promoting wellbeing). He reminded us of the cumulative effects of colonization on Canadian Indigenous peoples and spoke about how the Indian Act prevented First Nations from participating in their traditional economy, while also preventing their participation in the new economy. He said that, really, the purpose (if undeclared or unacknowledged) of the Act was to get Indigenous communities to die out - or at least be subsumed - but they confounded things by surviving. However, the Act created a norm of dependency in communities.

Kinew’s father was a residential school survivor. In describing the experiences of his father, Kinew alluded to the film Resilience and asked those of us who had watched it earlier in the day to consider the toxic stress of being taken from a close knit community to be raised in an alien educational and religious environment that was systemically abusive in a state of near-starvation and even subjection to unethical nutritional research. “There was a cemetary but no playground.” Kinew spoke about how he always thought that his father hated him and realized only at the age of 28 that his father was just unable to show his love because he had never known what it was to experience the showing of love….behaviour learned in one generation and passed down, the recently articulated ‘intergenerational impact of residential schools’. This compounds with modern influences such as social media, socio-economic problems such as high basic food prices in the arctic, and ongoing acculturation and language loss to lead to a perpetuating cycle of poor health and wellbeing in indigenous communities.

However, Kinew’s talk was not all doom and gloom. “We are in an era of reconciliation,” he said. He credits the 6 year process of the Truth and Reconciliation Commission, which he says worked hard to win the respect and trust of residential school survivors (including his father) and produced a most ‘remarkable document’ in the form of its report last year. He praised its calls to action for the health care community, such as consistent measuring and reporting of health outcomes in indigenous communities; mandating of education on cultural safety and cultural competence for health care practitioners; and strategies to train more indigenous practitioners. Kinew also hailed the positive effect of what he calls an “Indigenous resurgence” – the reemergence of indigenous culture, which, he said, has mainly been lead by women who have been empowered by education. “Culture and language are important,” he said, “…they – and talking about the traumas of the past - are key to fighting suicide, substance abuse and determinants of ill health.” The model for reconciliation can be adopted by all of us. We must remember that some of it can be brought about by civil society working together with communities and “the healer is not on the outside; he/she is part of it.” It’s not just about waiting for government to legislate.

We must embrace mutual accountability. "Let us not let another generation of children become elders before we stand up and do something."

 

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