00:00:00:02 - 00:00:27:15 Adam Hocking Welcome to The Rounds, a podcast of Marshfield Clinic Health System. I'm your host, Adam Hacking. The rounds brings together medical experts to discuss fresh, fascinating and important topics from the world of health care. How we're raised and socialized has a huge effect on the kind of adults we become and the lives we ultimately live. But as a medical profession, we're just beginning to understand the deep and complex impact that traumatic events or a sustained, traumatic childhood can have on human development. 00:00:28:01 - 00:00:49:06 Adam Hocking We're learning that trauma not only affects our mental health and emotional development, but that can also physically change our brains. Here to help us better understand what trauma is and how it impacts children in particular is Dr. Kristen Iniguez. As medical director of the Marshfield Clinic Child Advocacy Center, Dr. Iniguez specializes in caring for children who are potential victims of abuse. 00:00:49:12 - 00:00:59:04 Adam Hocking Dr. Iniguez completed medical school at Midwestern University, Chicago College of Osteopathic Medicine, and is also board certified in Pediatrics. 00:01:02:19 - 00:01:05:16 Adam Hocking Dr. Kristen Iniguez, thanks for joining us on the rounds today. 00:01:05:21 - 00:01:06:10 Dr. Kristen Iniguez Thank you. 00:01:07:04 - 00:01:21:00 Adam Hocking Now, when it comes to trauma, that's a word that's in our common vernacular. We all have sort of a working definition of what trauma is. But I think that's a general sense in the psychological sense or in the sense of your expertise. What is trauma mean? 00:01:22:07 - 00:01:39:11 Dr. Kristen Iniguez The term trauma is evolving and it is fairly new still, in a sense. Trauma can refer to, you know, harm in general to the body. And so I think people generally tend to think of, you know, coming into a trauma unit in. 00:01:39:11 - 00:01:40:12 Adam Hocking The trauma surgeon. 00:01:40:16 - 00:02:02:16 Dr. Kristen Iniguez Right. But when we talk about this form of trauma and psychological trauma, it is any event, whether that be a physical thing or something that makes you essentially it undermines your sense of health and safety for your own, your own self. 00:02:03:17 - 00:02:15:22 Adam Hocking And so what does trauma look like? How do you start to identify it? And maybe you can talk about sort of your expertise as it as it relates to to children showing signs of trauma? 00:02:16:21 - 00:02:44:17 Dr. Kristen Iniguez Well, I think it's it's first important to talk about kind of what what trauma, how trauma is caused. Okay. And so I think like I mentioned, trauma comes in all shapes and sizes. And it can be, again, something like physical abuse or sexual abuse or being exposed to a significant natural disaster, being in a fire, being in a car accident, developing an illness, having a surgery. 00:02:45:00 - 00:03:10:00 Dr. Kristen Iniguez So there's all sorts of things again, that that count as trauma. And it's really up to the individual as far as how they perceive that and how life threatening or threatening to their body, they perceive these events. There's also things that are not necessarily physical. So we talk about emotional abuse. So when a person yells at you, calls you names, and generally undermines your sense of self-worth. 00:03:10:07 - 00:03:39:09 Dr. Kristen Iniguez That also is traumatizing. And emotional neglect where, let's say you just don't get the nurturing and responsiveness you need from your caretakers. That also is traumatic. Then there are things just in our daily lives that can be kind of an underlying smoldering trauma. Living in poverty actually has traumatic effects on the brain, not knowing where your next meal is going to come from, not knowing where you're going to sleep tonight. 00:03:39:17 - 00:03:45:11 Dr. Kristen Iniguez Those are all things that really, again, can affect the way a brain functions. 00:03:46:04 - 00:04:11:09 Adam Hocking And is it more in the folks where you see the long sustained trauma, maybe a person that grew up in a physically abusive they had physically abusive parents. Do you see a bigger trauma response in those types of people that lived in those situations typically than someone that just went through? I don't know if there is such a thing as a normal life, but I mean, they had traumatic experiences maybe here and there, but but their environment was more or less healthy. 00:04:12:06 - 00:04:22:02 Adam Hocking Where do you see a difference in and sort of how does it make a difference how long people have been exposed to drama, to trauma in terms of the response they have to it? 00:04:22:07 - 00:04:47:18 Dr. Kristen Iniguez Not necessarily. And you you hit the nail on the head when you mentioned, you know, living in a relatively healthy environment and a person's ability to respond to trauma is a function of their level of resilience. And resilience is your ability to overcome that. Now, individuals who, let's say, don't have a lot of support in their life are going to deal very differently with any of these types of traumas that I've mentioned. 00:04:48:01 - 00:05:01:01 Dr. Kristen Iniguez But if you've got somebody in your in your life, whether it's a parent or grandparent or a teacher or a, you know, a parent of a friend who's there to help support you and help you overcome that, you're going to do better overall. 00:05:01:13 - 00:05:14:22 Adam Hocking And so what is the what is the experience of being traumatized, exposed to trauma? What's the effect? What does it do to people? And how do you distinguish it from depression or anxiety or something else like that? 00:05:15:07 - 00:05:40:18 Dr. Kristen Iniguez Well, and it all depends. It depends really on the level of or the stage of development that, let's say, if this is a child we're referring to, what stage of development they're in when the traumatic experiences occur. The younger you are and, you know, theoretically, the more potential damage can be caused by either a single significant event or multiple kind of chronic smoldering events. 00:05:41:07 - 00:06:01:23 Dr. Kristen Iniguez But we can even experience trauma as adults, and that can have an effect on how our brain works as well. What we see with children, especially in those critical times of brain growth from about 0 to 5, it actually can have a significant effect on what we call neurobiology, which is how the brain grows and how the brain functions. 00:06:02:08 - 00:06:31:04 Dr. Kristen Iniguez So in children that have significant chronic abuse or neglect, we see that their brains can be smaller, literally. So it affects the volume, but it also then affects how the brain works. And so it doesn't work as well. And we can see effects in all sorts of domains, including kind of emotional and behavioral health in their intellectual health, their ability to relate to others and have develop and sustain relationships as well as their physical health. 00:06:31:12 - 00:06:39:04 Dr. Kristen Iniguez So it can come out in all sorts of ways and that these all can be very detrimental for their lifelong success. 00:06:39:17 - 00:06:45:04 Adam Hocking And you're saying even if you're emotionally abused, it can change the physical makeup of your brain? 00:06:45:10 - 00:06:45:20 Dr. Kristen Iniguez Yes. 00:06:46:11 - 00:06:50:01 Adam Hocking Do we know the function of kind of how that's happening or why that's happening? 00:06:50:13 - 00:07:16:16 Dr. Kristen Iniguez Still, it's an early science, but one of the things that we know is that any type of trauma, again, whether it comes in the form of abuse, neglect or something else, it affects our stress responses. And, you know, stress is a normal thing. It's a good thing. It you know, our body recognizes new stimulus, new experiences, and has to determine whether those are safer, unsafe. 00:07:17:00 - 00:07:40:03 Dr. Kristen Iniguez If your body if your brain experiences something that is new, it's going to alert you to that and it's going to set off a stress response. So let's say somebody were to bolt through the door here. That's going to start less because we don't know what's going to happen next. But as soon as we realize that, you know, it's one of your colleagues or one of my colleagues, you know, our brain tells itself to settle down and we go back to normal. 00:07:40:12 - 00:08:00:02 Dr. Kristen Iniguez Right. But if that person storms the door and threatens our safety in some way or, you know, any other event like that, that can raise our stress response and we can then have a chronic stress response from that. So every time someone walks through the door, you think it's a threat versus, you know, just a friend or colleague. 00:08:00:08 - 00:08:06:08 Adam Hocking So someone that has been traumatized, their brain is trained to have that sort of immediate stress reaction regardless of the situation. 00:08:06:12 - 00:08:06:22 Dr. Kristen Iniguez Yes. 00:08:07:08 - 00:08:23:19 Adam Hocking You said to me at one point, I think off air when we were talking about trauma, that trauma sort of overlays everything of all the sort of diagnoses that are out there. Trauma really needs to be thought of as is kind of overlaying all of that. I wonder if you could talk about what you what you meant by that. 00:08:23:19 - 00:08:54:13 Dr. Kristen Iniguez Sure. You can either say overlay or I even take the foundation. So one of the pushes for the clinic health system are the ABCs, and that refers to kind of a platform of working with individuals who have alcohol and other drug abuse problems, behavioral health issues or chronic disease. And when you take each of these individually, if you were to drill down for many of our patients that suffer from any of those those issues, you'll find that they likely have significant trauma in their background. 00:08:54:17 - 00:09:19:01 Dr. Kristen Iniguez Not everybody, but many, I would say. And again, because of what chronic trauma does to the brain, neurobiology, it makes us more prone to risk taking behaviors. So let's say, for instance, an individual who has developed toxic stress, is this change in the brain. They might develop symptoms similar to depression because of that trauma and we might self-medicate. 00:09:19:02 - 00:09:40:20 Dr. Kristen Iniguez So alcohol or an opiate might help us feel a little bit better. Some people, you know, choose to try methamphetamine, which is highly addictive and become it becomes a problem fairly quickly. Behavioral health issues, again, I've already mentioned that when the brain neurobiology has changed, it can manifest in many different ways. And depression and anxiety are one of those ways. 00:09:41:03 - 00:10:06:07 Dr. Kristen Iniguez We have some children that are even misdiagnosed with autism when their problem is actually traumatic experience, not organic autism. We see a lot of children diagnosed with ADHD as well and medicated for that when it is not organic ADHD. And then from a chronic disease perspective, we know that when our traumas build up, the more traumas we have, the more likely we are to have poor health outcomes. 00:10:06:14 - 00:10:31:19 Dr. Kristen Iniguez And that has a lot to do with excess cortisol again. So our stress response and basically an excess stress response, excess cortisol release is like taking prednisone every single day and we can see all sorts of health problems from that, including heart disease, high blood pressure, muscle wasting, osteoporosis, glucose insensitivity and diabetes, you know, autoimmune disorders, all sorts of things. 00:10:31:19 - 00:10:34:03 Dr. Kristen Iniguez So so that really speaks to your ABCs. 00:10:34:11 - 00:10:54:03 Adam Hocking In terms of of trauma. I don't remember hearing about too much about this type of trauma in popular culture until the last few years, maybe in the medical community. And in your experience, how long have we been looking at trauma this way? Are we kind of scratching the surface, or is it more well-known then than maybe we know. 00:10:54:09 - 00:11:22:10 Dr. Kristen Iniguez We are scratching the surface? And in fact, I would say in most medical communities, it really isn't recognized or understood to the point that it needs to be because it does underpin underpin excuse me, most of the again, not most, but a lot of the problems we're seeing in our patient population. It wasn't until the 1980s where this really started to come onto the radar and to me to speak to the Asia study because that's where we started. 00:11:22:23 - 00:11:58:19 Dr. Kristen Iniguez So in 1985, a physician out of California recognized that traumatic experiences were leading a lot of his obese patients to drop out of his weight loss clinic. And that led to then a survey of 17,000 insured Kaiser Permanente customers in California. And they found that individuals who disclosed having adverse experiences in childhood, including abuse, neglect and other household dysfunctions, had significant issues with emotional and behavioral health and in poor physical health outcomes as well. 00:11:59:06 - 00:12:12:06 Dr. Kristen Iniguez So that's really that that study was published in 1998, and that is really when everything started to take off. And it's slowly gaining momentum, but still has a long way to go. 00:12:12:22 - 00:12:24:10 Adam Hocking How do you separate one of the ideas that I've come across, as I've done a little research on trauma is attachment, childhood attachment. How does that sort of interplay with trauma or does it? 00:12:24:23 - 00:13:03:09 Dr. Kristen Iniguez Oh, absolutely. So we talk about the emotional neglect piece, for instance, and this is when a child, an infant or young child is in a an unresponsive environment or unresponsive in a non nurturing environment. And one of the key factors with brain growth is experiences. An infant needs to have millions and millions of experiences for that brain to grow Every time there is an experience, whether it's something that they see, they hear, they taste, they touch, they feel that causes a neuron to connect with another neuron. 00:13:03:18 - 00:13:31:12 Dr. Kristen Iniguez And every time they re-experience that, it strengthens that circuit. Without those experiences, our brains don't grow the way they're supposed to, and they don't learn to function the way they're supposed to. And so really, it's attachment is a very, very important part of dealing with trauma or being able to overcome traumatic experiences. It goes along with that resilience piece that we were talking about earlier. 00:13:32:06 - 00:13:57:07 Adam Hocking I wonder if you want to talk about it. I can turn it up if you like, but I'd wonder I wonder if you want to talk about the the Eucharist, the Eucharist early intervention project, because I think that's a decent Segway from talking about attachment and childhood development, to have sort of an actual specific example where we almost unfortunately had a real life laboratory for kind of research on how trauma impacts children. 00:13:57:13 - 00:14:01:07 Adam Hocking Do you want to talk about sort of what that was and what we found? 00:14:01:22 - 00:14:29:02 Dr. Kristen Iniguez Yeah, absolutely. I think I think it's very important. So in the seventies and eighties in Romania, they were under a communist regime and parents were essentially mandated to institutionalize their children and put them in orphanages so that they could go to work for the state government. Over 100,000 children were eventually institutionalized and raised in an orphanage, and they were stratified by health. 00:14:29:03 - 00:15:00:07 Dr. Kristen Iniguez So your healthier kids were placed in certain, maybe slightly better resourced facilities. But the children that were born with any kind of medical or physical impairment were placed in places where there were not a lot of resources. Regardless, that the conditions were pretty abysmal for anybody in this in these settings. And these children were essentially fed three times a day, but had very little caretaker interaction outside of, again, feeding them and changing their clothes. 00:15:00:16 - 00:15:29:13 Dr. Kristen Iniguez In many cases, they were handcuffed to their cribs. They got very little activity. And again, just no or very little face to face interaction with adult caretakers or other children, for that matter. And when the government was eventually overthrown, several physicians and researchers from the U.S. were able to go over. And this is a study that would never pass an institutional review board, would never get IRB approval in this country. 00:15:29:19 - 00:15:48:02 Dr. Kristen Iniguez But because of the circumstances, they were able to take some of these children and place them in foster care, some of them and some of them remained in the institution. They didn't have enough families for them to go for them all to go into foster care. And they were able to study and see what effects A that these children had from just being institutionalized. 00:15:48:07 - 00:16:08:03 Dr. Kristen Iniguez But then at what point in their life was kind of the breaking point for being able to recover from the traumas that they had experienced. And I will add that when the children were institutionalized, not not only did they experience severe emotional neglect, but there were also rampant physical and sexual abuses and other, you know, other terrible things going on there. 00:16:09:01 - 00:16:34:21 Dr. Kristen Iniguez One of the one of the slides that I like to show when I speak about this is comparing to three year old brains, one from a child who was living in a, quote unquote, normal nurturing environment and the other was a child that lived had been raised in one of these institutions. And the the size of the institutionalized, institutionalized child's skull was significantly smaller. 00:16:35:03 - 00:16:49:08 Dr. Kristen Iniguez The brain was significantly smaller and the amount of mass was smaller. So it's you know, it's obviously a very visual thing, but it was a very drastic difference that for a child who did not get all the nurturing that they needed, their brain didn't grow appropriately. 00:16:49:22 - 00:17:12:13 Adam Hocking So obviously, we can see there's a huge environmental component to the trauma response. Is there a genetic what do we know about sort of genetic resiliency? You know, might might you be more resilient than than I am in terms of responding to the same trauma? Or is it also fluid because we have such different backgrounds? 00:17:13:09 - 00:17:39:17 Dr. Kristen Iniguez Resilience is not something you're born with. It's something that really has to be almost taught and nurtured in a sense. And it goes back to when we mentioned the attachment template. When you have a caregiver that responds to your needs as an early infant, even though these infants aren't having cognitive thought, Oh, this person cares for me. It teaches them that when they cry, someone's going to come and feed them. 00:17:39:17 - 00:18:01:09 Dr. Kristen Iniguez Someone's going to come and change them, someone's going to take care of them. And it gives them first a view of themselves as being cared for. And eventually that that portends to having a feeling of self-worth. It teaches them that the caretakers around them do care about them and will respond to their needs and that they can trust those caretakers. 00:18:01:20 - 00:18:22:07 Dr. Kristen Iniguez But it also teaches them that the world around them is something that is fun and exciting and explorable and, you know, and it really gives kind of that more long term positive view. Whereas if you have a child who has very poor attachment, doesn't get a lot of nurture and responsiveness in their environment, it's the opposite. They tend to have less self-confidence. 00:18:22:13 - 00:18:31:07 Dr. Kristen Iniguez They don't have as much trust in others, and they don't look at their world around them as being a place that is good and that that, you know, they're going to have a future. 00:18:31:07 - 00:18:45:01 Adam Hocking And so when you talk about the differences in resilience between one person in the next, is there a way to build that resilience in are there practices or is there anything a person can do to become more resilient? 00:18:45:16 - 00:19:19:03 Dr. Kristen Iniguez Well, and it's not something that I think most people instinctively think about improving about themselves necessarily. It's not at least not children. But we know that resilience can be built in multiple domains. So probably the most important domain is relationships. Again, going back to attachment, they need to feel that somebody cares about them, right? They need to feel that they have some sort of support and it can be or ideally it's a caregiver, but it can also be a teacher, it can be a fireman, it can be anybody in the community. 00:19:20:01 - 00:19:47:14 Dr. Kristen Iniguez Some other ways, I think from a community standpoint that we can really help build resilience in our children is to, first of all, give them a safe community to live in and give them lots of opportunities. So safe parks where they can play and not have to worry about any kind of violence, have community activities where they can participate, having more cultural traditions or even just, you know, community wide traditions that they can feel that they're a part of. 00:19:48:08 - 00:19:53:10 Dr. Kristen Iniguez Resilience has really built, again through relationships. And that's kind of what this is all about in the end. 00:19:54:12 - 00:20:18:19 Adam Hocking One of the things I think we talked about in the past when we were preparing for the podcast is that trauma can be intergender racial, that it can pass on from one person to the next, from a mother to her daughter. Can you kind of talk about how that occurs? Is it is it a DNA thing where once you have a traumatic experience, it kind of gets baked into your DNA and you pass it on that way? 00:20:18:19 - 00:20:19:20 Adam Hocking Or how does it work? 00:20:20:16 - 00:20:25:10 Dr. Kristen Iniguez Baked in is not exactly the phrase I would use. 00:20:25:10 - 00:20:26:06 Adam Hocking It's not a medical term. 00:20:26:17 - 00:20:57:23 Dr. Kristen Iniguez Well, I like it. I like it. There's a there's a a field of science called epigenetics. And it looks at how do our experiences affect our DNA and therefore our our subsequent generations. And when we experience trauma, we can have some changes to our DNA. Now, our DNA itself doesn't change. The all of the base pairs are still exactly the same, but there are these little pieces called methylation in products that actually attach to our DNA and then change the way our DNA express how they function. 00:20:58:09 - 00:21:47:04 Dr. Kristen Iniguez So kind of turning some genes off and turning some genes on, we can actually pass those methylation products along in our reproductive cells to our subsequent generations. And what's interesting is that any experiences that my mother had are already encoded essentially into some of my reproductive cells that then I pass along to my children as well. And not only that, when a woman gets pregnant, if she has any adverse experiences during her pregnancy, let's say maybe using drugs or being a victim of domestic violence, her stress response also affects the fetus and essentially gives them a vicarious stress response that could potentially cause some epigenetic changes at that time as well. 00:21:47:13 - 00:21:53:10 Dr. Kristen Iniguez So there's unfortunately multiple ways that experiences can affect our future generations. 00:21:53:15 - 00:22:01:11 Adam Hocking Trauma informed care is kind of in vogue term right now. What does it really mean to practice trauma informed care? 00:22:02:09 - 00:22:26:06 Dr. Kristen Iniguez To be totally honest, it's just being a good person. You know, when we see the person on the street or in the hallway, we smile, we make eye contact, we make a connection. We don't ignore, we don't. One of the things that I hate the most when I go to a place and someone's you're waiting in line and the person just won't even make eye contact with you and acknowledge you before you stepping up to the window. 00:22:26:17 - 00:22:46:13 Dr. Kristen Iniguez If I were in a poor mental state, that might actually get me pretty upset. Trauma informed care is a buzz word. I think it's an important buzz word, though. And to me, what it means is that we should know what trauma does to the people around us, what it's done to us as well. But we in our clinic like to think of it. 00:22:46:13 - 00:23:05:11 Dr. Kristen Iniguez We we like to break this down a little bit more. And we do talk about being trauma informed. And again, that's just having a general knowledge. But then there is the point of being trauma responsive, and that would come down to individuals, let's say, in the health care system, law enforcement, child protective services, knowing that when you have somebody who has experienced trauma, how do you respond to them? 00:23:05:12 - 00:23:16:19 Dr. Kristen Iniguez Teachers as well in the school systems? And then another layer is something known as trauma specific services. So truly having services that speak to an individual's trauma to help them heal from that. 00:23:17:14 - 00:23:34:14 Adam Hocking I'm wondering about treatment for somebody that has experienced severe trauma. Does it express itself sometimes in depression and then you treat that depression or anxiety or you treat the anxiety, or is there a playbook for for treating trauma? 00:23:35:12 - 00:24:04:23 Dr. Kristen Iniguez One of the most well known courses of treatment for trauma is through therapy. And in fact, one of the probably most studied forms is what we call cognitive behavioral therapy. And that's talk therapy. And those tend to be very helpful, especially when you have an older individual who has decent executive functioning and they can sit in a therapy session and actually talk through their feelings. 00:24:05:12 - 00:24:30:17 Dr. Kristen Iniguez But one of the things that that we recognized with, especially these younger children and when trauma is experienced very early on, is children don't. Well, many of the children that we see don't technically have the executive functioning skills to be able to talk through their issues. And in fact, if their insults incurred occurred very early, they might have dysfunction in their brain stem, they might have dysfunction in their midbrain, in their limbic system and in and in their cortex. 00:24:31:01 - 00:24:36:22 Dr. Kristen Iniguez And so we have to almost start from the bottom and try to find ways to help them heal from the bottom up. 00:24:37:16 - 00:24:46:13 Adam Hocking I guess I'm curious if I can ask personally. This is such a fascinating topic to me. I'm wondering what makes you passionate about wanting to do this kind of work? 00:24:47:04 - 00:25:13:09 Dr. Kristen Iniguez I started off as a child abuse pediatrician. Well, really, I was a hospitalist first and got into child abuse early on in my career, and I've been practicing in that realm for about ten years. And always it's it's it's spoken to me for many reasons. But then I started to recognize kids going into foster care, especially had much more complex needs and really just needed more comprehensive care. 00:25:13:18 - 00:25:42:14 Dr. Kristen Iniguez And from a from a physical perspective, but also from a behavioral health perspective. And just seeing what these occurrences can do to a child who might already be behind the eight ball because they were born into poverty, but just knowing that they deserve a chance to be successful, they deserve a chance to have a healthy life with a strong, you know, upward moving trajectory. 00:25:42:22 - 00:26:07:06 Dr. Kristen Iniguez I think I you know, as as corny as it sounds, you know, they are our future. So we really need to do what we can do in our communities to take care of them and make sure that they have good outcomes. So at the Marshfield Child Advocacy Center, we developed a new service line. It opened officially about a year and a half ago and unofficially about two and a half years ago. 00:26:07:06 - 00:26:38:12 Dr. Kristen Iniguez And that's called the Resilience Clinic. This is a place where children who have suffered trauma of any of any type can come in for an evaluation. And our criteria for this for them to bring children into the clinic is that, A, they have had a traumatic experience, at least one, and that they have manifestations of that trauma and the manifestations can lie in, again, any domain, including behavioral and emotional health problems, physical health problems and intellectual health problems. 00:26:39:04 - 00:27:17:16 Dr. Kristen Iniguez And what we do is we provide an interdisciplinary team based approach to their care. So there is a medical provider myself at the table. We have a psychologist. Dr. Myra West is at the table. We have what we call an education specialist, which is a very new in. And I'll pat myself on the back for this very innovative approach where we have a teacher who is going to help us bridge between the child, their health care, their behavioral health care in the school system, and a social worker who rounds out our team and is our glue but helps with all of our wraparound resources and just making sure that some of those very basic needs 00:27:17:16 - 00:27:43:09 Dr. Kristen Iniguez are taken care of. Once the children come into the clinic, we do a very long, comprehensive initial evaluation and if they meet our criteria, they then segway into a behavioral health assessment. They are seen by our education specialist if they're school age, he would see them in the schools. He would also then work with the teachers in the schools to help develop what we call a trauma responsive classroom. 00:27:44:07 - 00:28:04:21 Dr. Kristen Iniguez And he works with the parents. And then again, our social worker kind of wraps all that up and make sure that they've got, you know, all of their insurance needs are taken care of, that they don't have any clothing needs or food pantry or things like that. They segway into therapy. And from there, then we evaluate them for twice a year as a full team again. 00:28:05:10 - 00:28:28:22 Dr. Kristen Iniguez And we feel that this interdisciplinary approach is really ideal for covering all of their needs. Plus we're working together very closely versus having a child go to a therapist over here and a doctor over there and, you know, some other specialist, and they don't really communicate very well. We're able to communicate and we're able to form a a plan that really speaks to this child's needs. 00:28:29:11 - 00:28:53:14 Adam Hocking You mentioned working with the schools. How important? One of the things we're seeing in health care in general is integrating care into people's communities is important because people that's where they live their lives. They don't want to go to the clinic or the hospital for everything, and it just doesn't work for them very well. How important is it for you to be out engaging with community partners in the schools and social services and things like that to do the work that you do? 00:28:54:00 - 00:29:11:05 Dr. Kristen Iniguez Very important. We have to break away from the silos. We have to break away from us working in our own respective buckets. We all have knowledge and expertise to share and we need to be sharing it amongst each other. And that's the best I think that's going to provide the best care for these kids overall. I'm going to give you a little bit of history. 00:29:11:12 - 00:29:37:12 Dr. Kristen Iniguez Back when I was coming up with this idea of the resilience Clinic, one of the gaps that I recognized was that the kids A, they had, you know, complex medical needs. So they really needed physicians who understood where they were coming from and how to provide care for them. They obviously have significant behavioral and emotional health needs. And we have our, you know, psychologists and therapists who have expertise in that area. 00:29:37:21 - 00:29:59:21 Dr. Kristen Iniguez But one of the biggest gaps was in the realm of education. Children in foster care, only about 50% of them graduate from high school and only about 10% of those in foster care go on to any kind of secondary education. So that kind of begs the question, what's going on from a cognitive or intellectual standpoint with these kids? 00:30:00:08 - 00:30:19:06 Dr. Kristen Iniguez And then as we started learning more and more about trauma, we recognized that when you have this chronic stress response, you can't pay attention. You're looking around the classroom at any little noise. You're afraid somebody's behind. You're going to hit you. And how can you pay attention to the chalkboard and read the chalkboard and then be able to test? 00:30:19:06 - 00:30:49:14 Dr. Kristen Iniguez Well, you know, so again, and a lot of these kids were labeled as being naughty or daydreamer or, you know, not paying attention for whatever reason. But really, in the end, they're just responding to their survival brain, as we like to say. And so by bringing in the education specialists and really and again, a very novel position, I believe our position is the only one in the country that I'm aware of that does what we do, being able to educate the teachers about these children. 00:30:49:21 - 00:31:10:00 Dr. Kristen Iniguez And keep in mind, too, that every intervention that we recommend can be used with everybody. You know, you don't naturally when a single child out in the classroom and say, well, you're you know, you're having a tough day, go over here. They don't like to have attention brought to them, just like we don't like having attention brought to us when we're having a tough day. 00:31:11:02 - 00:31:31:11 Dr. Kristen Iniguez But these interventions can be used with with the two of you. You know, they can be used with our colleagues, the rest of the classroom, and everybody benefits from that. So by teaching, by educating the teachers about what little tweaks they can make in their classroom to make this a more trauma responsive, classroom really just helps everybody overall. 00:31:31:19 - 00:31:50:15 Dr. Kristen Iniguez Our education specialist also, like I mentioned, works with parents because, you know, teachers can do what they do and maybe they're the best teacher. But if you go home to an environment where a parent doesn't understand how to deal with trauma, then you've just taken three steps back. So really getting our parents to recognize what trauma does to the brain as well. 00:31:50:20 - 00:32:16:18 Dr. Kristen Iniguez And how to respond to their children. And the last piece, which I think is so cool, is we're working with the kids, too. We're really empowering them to understand how their brains work. And that in and of itself, you know, again, gives them the inner strength to be able to implement some of these these tasks and these interventions that we're giving to them. 00:32:17:04 - 00:32:37:01 Dr. Kristen Iniguez You know, our mentality is we got to fix the kid, really. We've got to fix the child's environment. We need to, you know, And so there aren't a lot of things that I am aware of that we can send our parents to. You know, you can recommend parenting classes. I don't know that the quality of all the parenting classes is the same or of high caliber. 00:32:37:21 - 00:33:00:12 Dr. Kristen Iniguez So unfortunately, I wish there were more. And that's what that's one of our goals, is to really develop some programs that will help help teach our parents how to parent for whatever reason. You know, we have seen a huge breakdown in our family, our our intergenerational family units. You don't see the grandparents teaching the parents as much as we used to. 00:33:01:00 - 00:33:21:12 Dr. Kristen Iniguez And especially when we live in regions where there is a significant amount of poverty. That breakdown has occurred even more. Something else I thought would be I just gave a talk this morning so this is all fresh in my mind. Talking about the Aces again and talking about some of the kind of speaking to the epidemic of aces in our child population now. 00:33:22:01 - 00:33:49:06 Dr. Kristen Iniguez So when Dr. Felitti and Dr. and did their initial study with the 17,000 individuals, they found that, you know, generally most of the population has zero aces, or at least the largest number had zero aces or adverse childhood experience since I don't remember the exact numbers, but they found a threshold number of about four or more aces. And I think about 15% of their population had experienced four or more. 00:33:49:15 - 00:34:24:08 Dr. Kristen Iniguez And that was essentially a magic number in that that's when they saw higher rates of problems with behavioral health issues, emotional issues, physical issues, risk taking, behaviors and whatnot. We've repeated that study here in central Wisconsin. Rachel, Stan Koski and I published our data a couple of years back and we found fairly similar results. One of the things that we found that was different from the National data was that our rates of emotional abuse here reported by our surveyed population. 00:34:24:13 - 00:34:56:05 Dr. Kristen Iniguez We found that about 40% of the respondents said that they had been emotionally abused. And we compared that to the national data and it was only about 25% for the national data. So that was really interesting for us. But something else to keep in mind is that, you know, these are results coming from adults 18 and up. When Washington State did a similar survey with children in their state, they found that now up to 30% of their kids have experienced four or more aces. 00:34:56:11 - 00:35:13:09 Dr. Kristen Iniguez So this is really an epidemic amongst our current children. And I would expect the numbers are going to be going higher and higher because if you have more aces and your outcomes are poor, what's going to happen to your subsequent children down the road? So we have to be very aware. 00:35:13:23 - 00:35:20:18 Adam Hocking And do you attribute the rise in in these experiences to the breakdown in the family that you had mentioned? 00:35:21:03 - 00:35:43:03 Dr. Kristen Iniguez I think it's hard to say for sure. There's obviously multiple factors. I do believe that that is part of it. And again, every subsequent generation that suffers from alcohol and drug use, physical abuse, neglect, you name it, it will snowball. So I think that probably has a large role to play. But I don't know that there's any data that says for sure at this point in time. 00:35:43:21 - 00:35:46:20 Adam Hocking Dr. Kristin Iniguez, thank you so much for joining us on the rounds. 00:35:47:04 - 00:35:49:21 Dr. Kristen Iniguez Thank you for having me. 00:35:55:15 - 00:36:21:08 Adam Hocking The Rounds is produced by Ryan Maderic and supported by the Marketing and Communications department of Marshfield Clinic Health System. You can subscribe to The Rounds and download episodes via iTunes or by visiting shine.365.marshfieldclinic.org. I'm Adam Hocking and I hope you'll join us next time on The Rounds.