Jerry Active and a Horrendous Crime

I appreciate the outstanding comments. Tina, Mr. Active lived in a very small, remote community (850 Population) without many services. After his serious felony, one committed in a regional hub (2,400 Population), he served a prison sentence and was released into Anchorage (300,000). Shortly after his release he killed an elderly couple from an Anchorage minority community and sexually assaulted their granddaughter. The healthcare in his home community consists of what are referred to as "Community Health Aides" that have minimum requirements of a High School diploma and 4 months of training interspersed after every month's training with experience and mentoring. They work under the oversight of an MD by distance delivery. There are occasional visits to the Village by medical providers, typically ANP's or PA's. Behavioral health services are extremely limited. 

I agree that we are all struggling with how to address this issue. And we are all impatient to see results. We are all doing what we can to bring this important topic to our policy makers. I have spend about 5 years trying to bring the concept of developmental trauma into the policy lens of the biggest and most important American Indian/Alaska Native policy organization in the United States. I finally heard mention of the ACE Study during it's last national conference. It takes a long time to bring issues to policy forums, and we are a part of that effort.

Thank you Paul, 

 

So just to clarify, drug companies (which I knew) have a vested interest in the status quo of maintaining illness but so do the very service agencies because we do not have a single payer system for health care.  Each silod group (however you spell that word), fights to gain the most money and clout for itself as an organization as opposed to serving the public good.   

 

Thanks Tina  

Good Morning, Again,

 

First, let me apologize for being (a bit) obtuse in my writings. Ha Ha! I tend to write primarily to public health managers and executives who are familiar with the deficits in our system.  I have survived in that world, where the only way you can get out with partial sanity is by being obtuse, and therefore not direct, in your thinking, suggestions and coaching. Let me try to clarify some of what I said earlier. If I were to describe to you what I see, the nation, as a whole, does not experience the fiscal benefit of a single organized, unified health care system.  This is why single payer systems work best - their efficiencies are amassed at a single point in the process and the incentives are translated into a single unitary flow.  A each stage in U.S. corporate process, health care systems seek to extract the money they feel should be theirs for their operating contribution (net profit).  The problem is that every year, every partner wants his share to get larger - and does not balance the impact of his growth on its connected partner.  Because health care systems are generally tax funded - either directly or indirectly - health care systems say "Just print more money".  This is the competition between people who want to provide access to support for the underserved and poor, versus others who would simply let them transition away (you notice how I didn't say die).  I watched data specialists and policy wonks spend millions and billions of dollars redefining important aspects of the problem and pursuing interesting questions, while the growth of those who died needlessly because they have not been screened or did not understand the importance of monitoring their blood pressure.  The health care system did not begin by establishing a rule book which said we must have one unifying vocabulary for the entire system and these words will mean the same, regardless of whether you are funding a Woman Infants and Children's Program funded by the Department of Agriculture, versus establishing eligibility to the Medicaid program, linked to the Department of Public Welfare and managed by staff who are motivated to follow the right procedure and don't make waves.  When San Diego County Department of Health Services were given the responsibility for running the Medicaid application program for low-income pregnant women in San Diego, we were told that the productivity rate could be no more than 2.6 applications per day.  We computerized the entry process (1988) and provided instructions to patients about the documents they needed to bring, purchased advertisements as reminders.  Our new Medicaid application  rate became 1 document per hour - or 8 applications per day per person a 300% increase.   Very few have said that, but I think this element - poorly organized incentives - is a MAJOR contribution to this problem. 

Moreover, medical care has been linked to pharmaceutical care.  Quite a number of patients want physicians to prescribe a pill that will solve their problems.  WITHOUT DOUBT, many of the health problems we face as Americans reflect our own biases, gluttony, lack of consciousness around exercise and commitment to comfort foot (which is invariably sweet). If the ignorance of the uninformed, is linked to a breech in the  protocol for health and longevity, it should not be a surprise that hundreds of thousands of patients are becoming diabetic, with no end in sight. There are consistently volumes of advertisements with pharmaceutical companies selling their products to consumers, and then encouraging them to go ask their primary care physicians or specialists.

So some public health advocates have begun a community education process where we are bringing the ACES data and information directly to the patient. We do that so we can begin to prepare him and her for addressing the burdens that might continue to come from masking the realities that have been hidden.  I read these ACE Connection documents regularly, now, because we want to prepare for the person or persons finding themselves in the position where they begin to disrupt a problem they have masked for years.  The last thing we want to do is to expose a wound without a treatment approach in advance. 

Our next conference on ACES and Adult Health will be in mid September.  Details to follow.

 

Be well.

 

Paul B. Simms

Oh and I forgot that Infant Active has Fetal Alcohol Spectrum Disorder (in the photo he has a small head circumference so I would not be surprised).   

 

Yes we need to look after the toddler very well!!!

 

I did want to say though concerning how to get the average person to care about ACEs a NCAR discussion: 

 

I don't know who Mr. Active murdered or assaulted, it could be someone from his community -- most likely poor or it could be the most well to do family in Somewhere, Alaska.  Some of us think we don't need to care about this because it won't affect us, we don't raise our kids that way, but wait --- what if it is the most Well-to-Do family in Alaska that Mr. Active attacked?   It could be.... no one is immune from this type of violence and we should not deceive ourselves to believe we are.   

 

It is in all our best interest to care and prevent such unnecessary human suffering and tragedy and primary prevention does not begin with a prison sentence. 

 

Thanks. 

I wonder if we will do better with the toddler that Mr. Active abused.  The sympathy is all for this child now, but it won't be in twenty years, if he or she doesn't get the help now.

Hi Paul,

I believe that you have tons of knowledge that is important for folks like me to understand but I have to say, I cannot understand what you write.  It isn't to the point so I cannot use the information.  For those of us with parents who are from rural areas with little more than a second grade education, could you write so that someone like me could understand?  I want to understand why service agencies aren't working together to help prevent these issues but I simply cannot understand you, the way you write is too complicated for me to understand.  (I hope that doesn't sound rude.  I am not trying to be rude at all.  I want to understand you because I think I could learn a lot).   Thanks.

I have seen folks like Mr. Active a lot too.  I see folks like Mr Active starting at 18 months of age coming to the pediatric office with the parental Chief Complaint of uncontrollable tantrums or even younger with sleep problems or colic. 

I have seen these kids referred to U. of Michigan Child and Adolescent Psychiatry --- but just wait --- it will be 12 months before baby Active can get in (BUT how good is child and adolescent psychiatry at University of Michigan for this child?  This is what they will do --- give a medication --- guanfacine or clonadine.    Generally there is no questioning about the psychosocial milieu that this child's brain is developing in.)    Michigan is notorious for this.  My psychiatrist is from U. of Michigan and every time I ask him about trauma and bring in the ACE study, he ignores me. My psychiatrists have been at UMich for 20 plus years and it is still the same, I say trauma is what I want help with, the docs tell me it is unimportant.  I walked the halls one day I was there and asked random child psychiatrists if they knew what the National Child Traumatic Stress Network was and the consistent answer, NO.  What is that?  When I went back at a future date, I decided to print out 25 copies of the ACE study and copies of stuff that I thought would be great from the NCTSN and I walked the halls in the department.  Doors were open everywhere and since I went to medical school there and did cancer research there, I kind of know what it is like there, so I feel comfortable walking the halls.   I just walked the halls and put information about the ACE study and the NCTSN  on people's desks.  Don't know if anyone bothered to read any of it but --- I still tried.   It is depressing to know that my psychiatrist is going to be speaking at the University of Michigan Child Abuse and Neglect Conference - with no understanding of the importance of the ACE study.  I think I might have to go to his session and bring up the ACE study -- by now he should have an opinion that he is willing to back in public.  I am annoying like that, I NEVER give up. 

Anyway back to Mr. Active.  So His symptoms started to manifest in infancy with colic and a difficult to console temperament, poor sleeping; then at 18 months temper tantrums, a referral to child psyche at 2.5 yrs (when he finally gets in for an appointment only to get a drug).   The drug doesn't work (since the environment has not changed --- the general pediatrician or FP doc is now charged with medication management or the doc refers the child back to child psyche when things don't go well --- which they seldom do.  The parent decides that child psyche is not helpful, maybe even the family doc or pediatrician is not helpful, they just give my child drugs why bother? 

So the child goes through the toddler years -- no real services because no one had the courage/training to ask about eco-bio-psychosocial factors.  

Now the child is in kindergarden.  He starts to act out, he talks out, doesn't sit still, swears at teachers.   He is kicked out of school and referred to you for ADHD management.

What do you do?   It is pretty simple, here is your adderall (the diagnosis made after a Vanderbilt form completed and a 10 minute discussion with the parent - mother only).   The Adderall doesn't work so you change to Concerta.  That doesn't help so you put your hands in the air "You need to see child psych.  Your child's symptoms are beyond my level of training."    Okay, child goes to psyche and is put on an antipsychotic.   You get to manage the dosing after the child comes back.  No one has learned that --- starting at 18 months this child has been physically abused, emotionally abused, physically and emotionally neglected,  mother is involved with multiple different boyfriends who beat her and both mother and her various boyfriends use various drugs, mother's housing is unstable and sometimes she has sold her body to get illicit drugs that she is using to try too manage the hole in her soul from her own childhood trauma. 

Now the child is in 6th grade --- is 13 years old --- mother is being beaten by a new boyfriend --- this kid is lost, overwhelmed, the antipsychotics and the concerta and zoloft and clonadine and all the other drugs aren't numbing him enough --- I think I'll try some of that alcohol / or that oxy on the table. 

Wow, I am 13 years old and my whole life I have been on my own --- I can calm down now:   Alcohol and Oxy's really take away this massive pain I feel inside, the unbearable anxiety --- for the first time I have found a drug that actually takes my pain away. 

AGE 15 DUI / 16 B and E / 17 Assault / 20 sentenced to 300 plus years in prison. 

(or for your typical internalizer --- shy, never speak, find alcohol or heroine at 15, generally quiet not many problems caused for others, becomes a junkie or alcoholic, not doing well in school just passed through -- suicide at 21)

We are all responsible!!!!!!!!!!!!!

When are we gonna get it?????

Good Morning, ACE Informing Colleagues:

I have had quite a bit of experience in managing public health systems at the local level.  There is a huge gap between the legislative forces which originate Federal funding and family support systems in communities where these services must be fulfilled.  In my opinion, there are three types of gaps that should be addressed for there to be real structural reform.  First, the disconnect in the language and the use definitions to define processes must be aligned.  Structural barriers arise because multiple systems are prevented from sharing administrative resources - a goal that would reduce administrative costs, if allowed.  Rather bureaucracies drive disallowances based on the sole use of their dollars for their problem.  We already know, however, that problems are shared and a governmental basis for support is meaningful.

Second, Innovation has been driven by visions of Returns on Investment, which are outgrowths of intellectual property, which drives the Initial Public Offerings. If we incorporate PUBLIC SERVICE VALUES into the human management equation, the rewards generated from facilitating a more usable system would remove the hostility from being managed by it. These end of process rewards waste time because they are not organized around families in need and they do not appreciate the millions and billions of dollars in dollars in needless resource consumption because the digital focus is at the end, rather than the front of the system, where assessment is needed.  There are many low-income families that would qualify for a number of services, but the bureaucracy treats them as poor people - disconnected, disregards, and generally being punished because they are poor.  This is the thinking of the Elizabethan Poor Laws - which should stay in focus whenever policy matters arise. (Remember, you cannot reason a man out of something that he has not been reasoned into) Rewards developed jointly will accomplish access to clearly identifiable, measurable resources and shift the burden of administrative costs from 25-30% to less than 5%.

 

Third, an effective system should understand the profile of the consumers with whom it interacts and for whom it is responsible.  In eras past, no news was good news (from the insurance industry's perspective)  At the same time, some students who needed mental health services, were not provided care and they continued to spiral downwards. Similarly, some persons were arrested as criminals, were actually not managing their medicine well and/or had not been evaluated or treated by a mental health professional.  The Affordable Care Act has taken a major step forward in ensuring broader access to health care. More than 12 million uninsured Americans now have access to health care. Sadly, however, many medical care institutions are still working through the problem of interoperability and not regularly sharing records.  The premise is correct, but a universal patient advocate  or care Navigator does not yet exist.  Their role is to ensure that once the consumer has health insurance, that he or she would use it to accomplish the screening needed necessary to early diagnose these patients - diagnoses that would start treatment and lower costs.  To do this, however, we believe patients should do their part.  This component means that take greater levels of responsibility for their own health behaviors  As we are working on the ground with low-income families every day (San Diego Black Health Associates, Inc. www.sdbha.org), we see the gaps in resources with families struggling to survive and having no primary care provider because they have no primary home.  I am encouraged to participate in this ACES community planning.  It seems that there are those familiar with the network where the patient meets the system.  Equity means being able to balance needs and resources and to do it in the public interest.  Communities have places of trust, where we can nurture, share, grow and protect each other.  We are now convinced that from a health care perspective especially, it takes a village to raise a family - and keep them healthy.  This means we must work together and share what we know.  Chaos comes when it appears there are no more choices. Perhaps this is where Transcendental Meditation emerges  Have our combatants relax and appreciate the reality that the best fight is the one not fought.  And if you want to best understand this population, convene a small group of families that have lost young people and ask them to craft a transition strategy that THEY want.  Perhaps, we will do this ourselves in San Diego and report the answers. how do we approach foster children, who struggle through a myriad of problems - their first being a stable and loving environment. We need to learn how to be the sweet inspiration that dawns answers to questions not yet asked. 

This is Paul B Simms, signing off this post in Southeast San Diego

A Luta Continua...

I have tentatively identified Mr. Active's father, and if I have the correct person, it's clear that he had at least 4 ACE's: an alcoholic parent, a parent in prison, an absent biological parent and domestic violence in the household. There are likely more, but I cannot tell from court records. There seems to be potential for 6+ based on my observations from my experience working in rural Alaska.