HCR 2-RESPOND TO ADVERSE CHILDHOOD EXPERIENCES   3:12:11 PM CHAIR KREISS-TOMKINS announced that the first order of business would be HOUSE CONCURRENT RESOLUTION NO. 2, Urging Governor Bill Walker to join with the Alaska State Legislature to respond to the public and behavioral health epidemic of adverse childhood experiences by establishing a statewide policy and providing programs to address this epidemic. 3:12:28 PM REPRESENTATIVE GERAN TARR, Alaska State Legislature, as prime sponsor of HCR 2, brought attention to the proposed committee substitute (CS) for HCR 2 [30-LS0277\J, Glover, 1/17/18, included in the committee packet and hereafter referred to as "Version J"]. She maintained that given the current fiscal crisis, the need for long-term planning, and the need to understand the state's "cost drivers," the time is right to discuss the issue of the public health crisis of adverse childhood experiences (ACEs) in Alaska and its impacts to communities and the state budget. REPRESENTATIVE TARR began a PowerPoint presentation, entitled "A Public Health Crisis: Adverse Childhood Experiences." She referred to slide 2, entitled "What are ACES?" and relayed that two physicians - Dr. [Vincent] Filitti and Dr. [Robert] Anda - in doing research on obesity, discovered a link between early childhood experiences and health problems in adulthood. This led to their 1998 study, in which they gave a ten-question quiz to enrollees of a health insurance program to assess their exposure to trauma as children. Based on the answers to those questions, each research subject was assigned an ACE score from zero to ten. REPRESENTATIVE TARR turned to slide 3, entitled "What Kind of Childhood Trauma?" and relayed that the quiz assessed trauma in three categories - abuse, neglect, and household disfunction. Two of the categories include behaviors that impact the person, such as physical abuse, sexual abuse, neglect, domestic violence to an adult family member, and having a parent in jail. REPRESENTATIVE TARR moved on to slide 4, entitled "What is your ACES Score?" and encouraged committee members to take the quiz on their own to get a better understanding of the exposures that are assessed by the quiz. She offered that doing so would help the members appreciate the information gathered and the potential of that information to influence policy and save money. 3:16:44 PM REPRESENTATIVE TARR referred to slide 5, entitled "ACES Studies in Alaska," and stated that there were two key findings from the ACE studies conducted in Alaska. The first is that childhood trauma is far more common and far more expensive than previously realized. She said that the finding that childhood trauma is "more common" is something of great concern. Alaska has a record number of children in foster care - more than 3,000 currently - and these children likely have experienced a great deal of trauma in childhood and are continuing to experience trauma. She referred to the category "neglect," and offered that the research demonstrates that prolonged neglect can be more damaging than physical and sexual abuse. She stated that the second key finding was that the impact of this trauma affects individuals over a lifetime and societies over generations. She emphasized the importance of that finding: the ACE study reveals the exposures to an individual that lead to undesirable health outcomes in adulthood; the impact to societies over generations has not been fully understood in the public policy context. She mentioned that the Office of Children's Services (OCS) often serves the second and third generations of the same families. REPRESENTATIVE TARR referred to slide 6, entitled "Select Negative Health Outcomes," and said that some of the negative outcomes listed are not surprising. Before the ACE studies, people referred to the "cycle of violence," in which individuals growing up with domestic violence in the home have a higher likelihood of committing violence. She said that what the ACE study discovered that was new was physical health problems as outcomes, such as liver disease and heart disease, which can be very costly. REPRESENTATIVE TARR turned to slide 7, entitled "Select Negative Health Outcomes," to point out the percentages of an outcome linked to high ACE scores. She relayed that the research shows that 40.6 percent of Medicaid spending can be linked to childhood trauma; Medicaid spending is prominent in state budget discussions; and there has been an increase of 30,000 Medicaid enrollees this year. To the extent that the increase in Medicaid enrollees is the result of early childhood trauma, "upstream" prevention activities become more important for influencing the outcomes and eliminating spending. REPRESENTATIVE TARR cited from slide 7 the "current smoker" outcome percentage of 32 percent and the "heavy drinking" outcome percentage of 20.5 percent. She referred to a McDowell Group report, entitled "The Economic Costs of Drug Abuse in Alaska, 2016 Update," prepared for the Alaska Mental Health Trust Authority (AMHTA) and the Advisory Board on Alcoholism and Drug Abuse (ABADA), which claims that the cost is in the billions of dollars. She emphasized that Alaska is paying for the costs through treatment, through courts, through incarceration, and through the handling of dysfunctional students in schools. She maintained that considering the cost to Alaska, there is great opportunity to makes changes and spend this money better. 3:21:01 PM REPRESENTATIVE TARR referred to slide 8, entitled "The Price of Not Intervening Before Trauma Occurs," to demonstrate potential savings: a 32 percent reduction in costs due to smoking would yield a $186 million in savings; a 20 percent reduction in [costs due to] substance abuse would yield a $350 million in savings; and a 40.6 percent reduction in Medicaid costs would yield a $350 million in savings. She offered that the proposed resolution mentions other statistics and explained that because of all the research in this area, costs and percentages are constantly being updated; in any case, the costs are significant and there are opportunities for savings. REPRESENTATIVE TARR referred to slide 9, entitled "Overcoming ACES in Alaska Building a Statewide Movement," to point out the many and varied organizations that have been able to "connect the dots" by looking at the outcomes, such as drug abuse, domestic violence, and suicide, through the ACE "lens", and thus understand that their issues are all interrelated. She gave an example: individuals with four or more ACEs are in the hundreds of percentiles more likely to commit suicide; Alaska leads the nation in suicide rates; if suicide prevention is directed toward young adults or teens, the opportunity may have been missed, because suicide may be the result of childhood trauma. She claimed that organizations such as Best Beginnings and Alaska Association for Infant and Early Childhood Mental Health (AK-AIMH) have been formed based on the recognition that early childhood experiences are integral to lifetime experiences, and there is opportunity to impact the subsequent issues by looking at them through the lens of ACE. 3:24:06 PM REPRESENTATIVE TARR turned to slide 10, entitled "Overcoming ACES in Alaska: Connecting people and policies," to point out additional work done in the state. She stated that OCS receives 50 reports of child abuse or neglect per day. Most ACEs happen to Alaska kids by age 3; therefore, waiting until early adulthood or adulthood to address the problem is too long. REPRESENTATIVE TARR moved on to slide 11, entitled "Overcoming ACES in Alaska" to present the three "asks" in the resolution. She maintained that the resolution does not request policy changes at this time; it is more focused on raising awareness and building the knowledge foundation around ACE, the research that has been performed in Alaska, and the opportunity for changing practices, improving health outcomes, and saving money. 3:25:07 PM ALISON KULAS, Executive Director, Advisory Board on Alcoholism and Drug Abuse (ABADA), testified that ABADA looks for the connections that Representative Tarr mentioned and ways to work with partners to reduce ACEs. She stated that ABADA has been able to partner with the Department of Education and Early Development (DEED), which created eLearning modules to inform teachers, school staff, and community members about ACEs and offer them a trauma-informed approach to intervening early in life. 3:26:50 PM REPRESENTATIVE KNOPP moved to adopt Version J as the working document. There being no objection, Version J was before the committee. 3:27:17 PM REPRESENTATIVE LEDOUX expressed her belief that ACEs cause some real problems in adulthood. She referred to page 2 of Version J, lines 6-10, and asked whether smoking and obesity were more the result of parents smoking and the foods they gave their children, rather than abuse. REPRESENTATIVE TARR maintained that ACE research is changing the understanding on those issues. She gave an example: many schools are incorporating "mindfulness" activities to address trauma by helping children self-regulate their emotions; activities often include meditative and deep breathing exercises. She maintained that some counselors believe that the link between smoking and a high ACE score is because smoking replicates a mindfulness activity; it involves deep breathing, but in the form of smoking. She claimed that the original [ACE] study is recent, and the information is new, therefore, has not been broadly applied in the medical community or in public policy yet. She emphasized the importance of the quiz and maintained that doctors are beginning to ask their patients the same questions [as on the ACE quiz] to better understand the origin of behaviors. REPRESENTATIVE TARR offered the term "epigenetics" and explained that everyone starts out with a genetic blueprint, but it is subject to change due to environmental exposures. She said that there are modifications and mutations to the genetic blueprint that may be related to later health effects. 3:30:00 PM REPRESENTATIVE LEDOUX asked if the quiz is in the committee packet. REPRESENTATIVE TARR replied, it is not. She stated that she would provide the link to committee members. She maintained that the collective ACE score of all 60 legislators would be interesting information. 3:30:38 PM REPRESENTATIVE WOOL expressed his appreciation with the study and his support of early intervention. He commented that he believes that there are some "leaps of faith" in the numbers provided by Representative Tarr: for example, 20 percent of people who smoke do so because of ACEs or 20 percent of people who drink heavily do so because of ACEs; therefore, without ACEs, 20 percent of the costs would be eliminated. REPRESENTATIVE WOOL relayed that he recently asked the principal at his children's school what she needed most. He said that she replied, "I need a social worker." He offered that children in elementary school today have more social problems than children a generation ago; dealing with those problems earlier [in life] would be advantageous. REPRESENTATIVE TARR referred to page 8 of the report, entitled "The Economic Costs of Adverse Childhood Experiences in Alaska" [prepared by Patrick Sidmore, MSW, for ABADA and the Alaska Mental Health Board (AMHB) and included in the committee packet], which read, "Population attributable risk is a well- established method in epidemiology of determining the percentage of an outcome which is linked back to a precursor". She said that this section of the report explains the science and methodology of determining the percentages. She maintained that often health data is difficult to obtain, and it is important to continue the research. REPRESENTATIVE TARR mentioned that the All Alaska Pediatric Partnership (A2P2) has been encouraging physicians to have conversations [about ACEs] with their patients; Alaska Native Tribal Health Consortium (ANTHC) has incorporated these discussions into their standard communications with patients. She emphasized the importance of this in dealing with the intergenerational trauma aspect of ACE. REPRESENTATIVE TARR stated that when one hears stories about a person getting into trouble, he/she rarely hears that the person came from a stable, loving home with an upbringing that offered opportunity; more often the person had a great deal of childhood trauma. She maintained that when looking at these issues through the ACE lens, instead of asking, Why did you do that? or placing the blame for the behavior entirely on the person, whether a child or adult, ask, What happened to you? She maintained that many of these behaviors are the result of "bad things that have happened to people" and people are only so resilient. Resiliency comes from protective factors, and protective factors include a stable, loving home. Children growing up without protective factors are hindered in their abilities to overcome trauma experiences. 3:34:53 PM REPRESENTATIVE JOHNSON offered that [ACE] exists to some degree but opined that the proposed resolution feels like "big brother" intrusion and "social engineering." She cited page 3 of Version J, lines 23-26, which read, "take into account the principles of early childhood and youth brain development and, whenever possible, consider the concepts of early adversity, toxic stress, childhood trauma, and the promotion of resilience through protective relationships, supports, self-regulation, and services". REPRESENTATIVE TARR answered that she disagrees. She relayed that she grew up in an abusive household and watched her brother struggle his whole life until he committed suicide. She expressed her belief that what is proposed under HCR 2 is not social engineering; children should not have to be beaten or sexually abused; children are innocent and have no choice or power in the situations into which they are brought; and caring for children is a moral responsibility. She reminded the committee of the 50 reports of child abuse or neglect per day coming into OCS; over 10,000 reports per year; and in the month of December there were several hundred reports of child sexual abuse. She asserted that there are children suffering unnecessarily, and the state has a role to play to end the suffering and give these children more opportunities in life. REPRESENTATIVE JOHNSON responded that she did not say that children should be abused. She emphasized that the legislature is not for abusing children. She maintained that not passing the resolution does not mean that the legislature is for abusing children. 3:38:30 PM CHAIR KREISS-TOMKINS announced that HCR 2 would be held over.