A clear and colorful sign is posted in every exam room at the pediatric clinic at Le Bonheur Children’s Hospital.
The sign displays a large, diverse and happy group of men, women and children, and delivers this message:
THIS IS A NO HIT ZONE
No adult shall hit a child
No child shall hit an adult
“Before we put up those signs, we had some uncomfortable conversations,” said Lisa Rogers, who manages the clinic’s Family Resilience Initiative (FRI).
“Now we have better conversations. We talk about the medical implications of hitting a child, especially the developing brain of a child who may already be experiencing chronic stress or trauma.”
A child’s developing brain is more advanced than the most powerful supercomputer, and more vulnerable.
Research shows that prolonged stress and trauma, often experienced in economically distressed homes and neighborhoods, can impair the normal development of a child’s brain and erode a child’s immune system.
”The chronic stress and trauma our children are experiencing on a daily basis is a public health epidemic. And the hallmark of public health is intervention and prevention.’’Dr. Altha Stewart, psychiatrist
Children of chronic stress, trauma and so-called adverse childhood experiences (ACEs) often become more anxious, impulsive, aggressive and hyperactive.
They become more prone to violence, aggression, depression, substance addiction, suicide, illness and disease, not to mention academic failure.
The problem is especially acute in high-poverty urban areas such as Memphis.
“The chronic stress and trauma our children are experiencing on a daily basis is a public health epidemic,” said Dr. Altha Stewart, a psychiatrist and founding director of the Center for Health In Justice Involved Youth at the University of Tennessee Health Science Center. “And the hallmark of public health is intervention and prevention.”
Decades of brain research is fundamentally altering our understanding of the causes of serious physical and mental illnesses and their lifelong and communitywide consequences.
Local health care leaders call it a public health crisis. In response, they are using brain science to study, diagnose and treat poverty and other social determinants of health as medical conditions.
Pediatricians and nurses at LeBonheur and psychologists at UTHSC are screening children for poverty and trauma and prescribing psychological and social services to help them.
Scientists at the U of M and UTHSC are using neurofeedback to treat developmental trauma in adolescents who are in trouble with the law.
Audiologists at the U of M are using new methods to treat charter school children with hidden, brain-based auditory deficits that disrupt their learning and behavior.
They believe their work will have a profound impact on children and adolescents who struggle to learn, communicate, behave and cope.
They hope it will have a lasting impact on a community struggling with the high cost of poverty, violence, addiction, obesity, and mental and physical illness
They trust it will lead to fundamental changes in our education, social service, juvenile justice and health care systems.
“We’re not fixing poverty here, but what we are doing can mitigate the impact of poverty, and especially its impact on children,” said Dr. Jon McCullers, pediatrician-in-chief at Le Bonheur and chair of pediatrics at UTHSC.
“That will have a significant long-term impact on systems and structures and policies and lives.”
The water-damaged ceiling in Sylvia Perry’s tiny North Memphis apartment was falling in and bringing rats with it. So she told her pediatrician about it.
“I tried getting help from my rent company. No answer from them,” Perry said. “LeBonheur helped me and my kids find a new place to live in. They helped me out a lot in my hardest times.”
Perry and her 4-year-old son, Antywon, are among hundreds of participants in LeBonheur’s Family Resilience Initiative (FRI), which opened in the clinic in May 2018.
When parents bring their children to the clinic for checkups, doctors and nurses do more than take their temperature.
They don’t just assess the weight, length and reflexes of a child’s body, and the size and shape of a child’s head. They also check the physical, social and emotional support system of the child’s brain.
They don’t just screen children for sickle-cell disease, hypothyroidism or other inherited disorders. They also screen for chronic stress, trauma and poverty.
“Because poverty so strongly influences a child’s health and development, pediatricians are asking about poverty-related stress, so we can connect families to resources in their communities,” said Dr. Jason Yaun, FRI’s director and lead medical investigator.
The American Academy of Pediatrics now recommends routine screening for poverty and other “social determinants of health,” as well as adverse childhood experiences.
It also encourages pediatricians to participate in programs that help children and their families reduce chronic stress and trauma in their lives and develop resistance to it.
Nearly all of the more than 250 families enrolled in FRI qualify for TennCare. Seven in 10 report a household income of less than $15,000 a year.
FRI’s outreach coordinators connect families directly to service providers and continue to check in on their progress and needs.
”If a mother is worried about her ceiling falling in, or how she’s going to feed her kids, or hearing gunshots nearby, she’s not going to have the wherewithal she needs to attend to her child’s needs. When you take care of a mother, you take care of a baby.’’Sandra Madubuonwu, LeBonheur FRI co-director
FRI families can receive referrals to UT psychologists.
They can participate in LeBonheur’s Triple P Positive Parenting Program.
They also can get help from Memphis CHiLD legal clinic — a collaboration with the U of M’s law school. CHiLD stands for Children’s Health Legal Directive.
If lack of transportation is keeping them from work, school meetings or medical appointments, FRI helps with bus passes or vouchers for Uber or Lyft.
If families indicate they need help with food, FRI connects them to a nearby food pantry or Neighborhood Christian Centers. If they indicate they lack adequate or affordable housing, FRI puts them in touch with MIFA or another local housing agency.
“If a mother is worried about her ceiling falling in, or how she’s going to feed her kids, or hearing gunshots nearby, she’s not going to have the wherewithal she needs to attend to her child’s needs,” said Sandra Madubuonwu, FRI’s co-director at LeBonheur.
“When you take care of a mother, you take care of a baby.”
Another mother brought her 4-year-old son to the clinic last October.
The boy had a history of asthma and eczema, two of the many chronic illnesses the Centers for Disease Control have linked to toxic stress in children.
He also had just been suspended from preschool for flipping chairs and other aggressive behavior.
“We discovered that he had witnessed severe verbal and physical abuse of his mother by his father,” Yaun explained. “The family had recently moved to Memphis for their own safety to get away from the previous situation.”
FRI’s outreach coordinators made referrals to a UT psychologist for the child, counseling services for the mother, and Neighborhood Christian Centers for more support for the family.
The child’s behavior has improved, and “the mother is much more aware of the related health issues and has career goals and has developed her own resourcefulness,” but the family is still facing difficulties, Yaun said.
“We haven’t been able to perhaps make as much of an impact as we would have liked,” Yaun said, “but we have actually been able to truly connect them with services and have true follow-up rather than just giving them a bunch of pieces of paper with phone numbers on them, knowing that they probably would not be able to access any of them. Hopefully we can prevent any future adverse experiences.”
Families can be powerful buffers against toxic stress in children.
Research shows that consistent, caring adults who are positive, nurturing and responsive can protect children from the harmful effects and help them become more resilient.
”We don’t look at this as a poverty issue. This is a child development issue. If the diagnosis is chronic stress and trauma, we need to find effective and evidence-based treatments – interventions and preventions that work.”Dr. Jason Yaun, LeBonheur FRI director and lead medical investigator
That’s why families who participate in FRI are asked such questions as:
“How often does anyone, including family, physically hurt you? Insult or talk down to you? Scream or curse at you? Threaten you with harm?”
The questions make families more aware of how such behavior can impair the normal growth and development of their child’s brain.
The answers help them find support. But LeBonheur isn’t trying to become just another social service provider.
“We don’t look at this as a poverty issue,” Yaun said. “This is a child development issue. If the diagnosis is chronic stress and trauma, we need to find effective and evidence-based treatments — interventions and preventions that work.”
SURVIVE AND THRIVE
The Family Resilience Initiative isn’t LeBonheur’s first effort to help families and their children build resilience to chronic stress and trauma.
Since 2010, the Nurse-Family Partnership has paired hundreds of first-time, low-income mothers with nurses who regularly visit their homes.
They guide the mothers through pregnancy until their child’s second birthday, helping them understand the benefits of attachment and nurturing, healthy diets and breast-feeding, language development and mental health.
Last month, NFP held its 11th graduation ceremony. The Class of 2019 includes 38 mothers and 39 2-year-olds. Several mothers spoke.
“Being a first-time mom, I didn’t really understand,” said Jasmine Bailey, mother of Isaiah. “Jill, our nurse, showed me how important is it not just to have a kid but to raise a kid. I am so grateful.”
NFP children, and especially boys, are healthier and have better academic, social and emotional skills, according to a 2017 study of the Memphis program by James J. Heckman, a Nobel laureate economist at the University of Chicago.
The study also found that NFP mothers have better parenting skills, mental and emotional health, and brighter futures. Isaiah’s mother stayed in college after he was born and she’s planning to go to law school.
“These mothers already have resilience in them,” said Madubuonwu, who supervised the NFP from 2009-2012. “Some do not have enough food or adequate housing or a job with a living wage, but they are still surviving. Our program empowers these young mothers, arms them with knowledge to help them build a buffering relationship with their child, not just to survive but the thrive.”
Brain science is informing several local programs to help families and their children build resilience to chronic stress and trauma.
“If you can’t take people out of trauma, what can you do?” said Linda Oxford, director of clinical services for the faith-based Agape Child & Family Services.
”Resilience-building is the only thing that offsets the reality of the toxic stress in their lives.”Linda Oxford, Agape director of clinical services
“One thing we can do is help them become more resilient and give them a better chance of surmounting the daily adversities they face. Resilience-building is the only thing that offsets the reality of the toxic stress in their lives.”
Agape is partnering with the Tennessee Department of Human Services to provide trauma-informed cognitive behavioral therapy and other counseling services to about 450 families in apartment complexes in Frayser, Hickory Hill and Whitehaven.
Tennessee’s Department of Children’s Services, meanwhile, is funding more than two dozen trauma-informed, resilience-building programs across the state through its Building Strong Brains initiative.
That includes programs with Shelby County Schools, Porter Leath and UTHSC, as well as United Way of the Mid-South’s Driving the Dream initiative, and Rotary’s Family Youth Initiative.
“The work will continue,” said Richard Kennedy, executive director of the Tennessee Commission on Children and Youth. “The General Assembly has allocated $2.45 million to fund ACE’s Innovation Grants. That money is recurring.”
Most of the FRI families have agreed to participate in a long-range clinical trial.
Yaun and other researchers are collecting blood and saliva samples from parents and their kids. As the children grow, they’ll also conduct stress, behavior and medical assessments and school test scores.
The goal is to measure the impact of FRI’s efforts to address unmet social needs and sources of toxic stress.
They hope the intervention will lead to fewer mental, physical, emotional and behavioral problems and help kids reach important developmental and educational milestones.
FRI’s clinical trial officially began last month. It’s scheduled to be completed in 2024. It will add to a growing, trauma-informed biorepository in Memphis.
Since 2006 researchers here have been studying how genetic, social, emotional and environmental factors influence a child’s development.
That’s when UT and the Urban Child Institute launched the CANDLE study — the Conditions Affecting Neurocognitive Development and Learning in Early Childhood.
The massive study began with 1,500 pregnant women.
Researchers planned to test and assess the physical and mental health and well-being of each mother and child for three years.
“We’ve got a million points of data that are providing invaluable information on childhood asthma, obesity, toxic stress and trauma, and resilience through early adulthood. Science can help us identify these issues, but it will be up to the Memphis community to solve them.”Dr. Fran Tyavsky, UT principal investigator
Thirteen years later, that study goes on. Researchers now hope to follow the kids until they reach age 21. They are examining the impact of everything from mold and lead and Vitamin D to chronic stress and trauma.
“We’ve got a million points of data that are providing invaluable information on childhood asthma, obesity, toxic stress and trauma, and resilience through early adulthood,” said Dr. Fran Tylavsky, UT principal investigator. “Science can help us identify these issues, but it will be up to the Memphis community to solve them.”
Last April, hundreds of local health, education and criminal justice professionals gathered at the University of Memphis for the Loewenberg College of Nursing ACEs Symposium: Awareness to Action.
They began talking about how to build a community of resilience. Families are the first line of defense against chronic stress and trauma, but they can’t be the last. Research shows that adverse community environments are just as damaging to young brains and lives as adverse childhood experiences.
“We have to accept part of our work is not just healing individuals, but working at the systems level, side by side,” said Dr. Wendy Ellis, project director of the Building Community Resilience Collaborative at George Washington University in Washington.
“We have to bring our systems to the table and figure out what their role is in continuing these vicious cycles. Inequity itself is the underlying stressor that leads to so much adversity and trauma in our communities. Without equity, you can’t hope for resilience.”
SCREENING FOR TRAUMA
For local health care leaders, efforts to build a more trauma-resilient community must begin with the science.
That means seeing chronic stress and trauma as, first and foremost, a public health issue.
“That’s why we put the word ‘Health’ in our title,” said Stewart, founding director of UTHSC’s new Center for Health In Justice Involved Youth.
And that’s why the center — and not the Juvenile Court — will run the new Shelby County Youth Advocacy Center, which will attempt to use trauma-informed services “to break the cycle of delinquency.”
Among its goals: “To identify and provide services designed to help resolve underlying issues that may lead to delinquency,” such as mental health problems, trauma, addiction or family dysfunction.
The center is opening this month on the UTHSC campus as a $500,000 pilot project.
“We’ve got to be more creative about how we respond to chronic stress and trauma, and we’ve got to let the science inform those responses.”Dr. Altha Stewart, UTHSC’s Center for Health In Justice Involved Youth founding director
“The center will be restraint-free, voluntary, family-friendly and trauma-informed,” Stewart said. “It will take funding. It also will take political will that we know what to do to help these children and we believe it is something we need to do.”
The need is clear, Stewart said.
In late July, she spoke at the National Juvenile and Family Court Judges conference in Florida. She presented preliminary findings of the center’s recent review of the case files of 359 youths who were in juvenile detention in 2017.
Seven in 10 had experienced at least one (and 40 percent four or more) of the following: abuse, neglect, medical trauma, family violence, community violence, school violence, natural or manmade disasters and witness to criminal activity.
More than half of them had experienced some disruptions in caregiving situations and/or had parents involved in criminal activity. A third of the girls and 15 percent of the boys were victims of sexual abuse.
Their symptoms included traumatic grief, hyperarousal, numbing, disassociation, and physiological dysregulation.
“Most kids involved in the justice system are not criminals,” Stewart said, who just completed a term as president of the American Psychiatric Association.
“They are part of a public health epidemic. In fact, given where we are and the level of poverty here, we should assume that all kids in this community are living with unhealthy levels of trauma.”
Stewart believes local schools should screen all children under age 10 for chronic stress and trauma, just like they screen them for vision and hearing problems.
She’s convinced the results would show the need for more mental health counselors in the schools, and the need to revise behavior and truancy policies.
She believes that suspensions and expulsions, corporal punishment and zero-tolerance behavior policies don’t help and likely do more damage to children of trauma.
At least half of the youths in the juvenile detention study had been suspended from school and a quarter had been expelled.
“More kids have been exposed to trauma than schools can handle right now,” she said. “We’ve got to be more creative about how we respond to chronic stress and trauma, and we’ve got to let the science inform those responses.”
This story first appeared at www.dailymemphian.com under exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.