April 7, 2013 in Features

Taking on trauma

In response to a body of research linking adult health problems with adverse childhood events, educators and others are revising their methods to help children and families learn and succeed.
By The Spokesman-Review
 
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Third-grade teacher Lauren Waterbury chats with students including AJ Dutton, left, and Noraa Christensen, in the green shirt, at Otis Orchards Elementary.
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Yellow buses pull up and open their doors, and children push into the school in waves.

Five teachers waiting in the foyer greet them as individuals. Each gets eye contact, a “good morning” or a side-hug or a question. The teachers aim to notice: Is anyone walking with their shoulders hunched? Crying? Paler than normal?

One teacher notices some missing baby teeth, and a small girl smiles proudly. The principal stops a taller boy to ask if he’s still doing safety patrol and ask him about his work.

Another boy enters in tears, escorted by his great-aunt. “He says he’s sick,” she tells the principal, Suzanne Savall, and the principal doesn’t seem surprised.

Savall guides the boy into her small office, and he sits at a round wooden table with a mini Zen garden at its center. She gives him a weighted blanket and a set of noise-blocking headphones.

After a few minutes, he’s stopped crying. Living with his grandma and aunts, he’s the “man of the house now,” Savall says, and that’s a tough job. “It’s a worry for you, isn’t it?” she asks him.

Worry can make you sick. It happens.

Within a few minutes, the boy is headed off to his classroom, escorted by an older student mentor.

‘Call to action’

Otis Orchards Elementary School, in the East Valley School District, is one of six elementaries in the Spokane area where staff members are using “trauma-based” techniques to work with students whose personal lives threaten not only their academic success but their overall well-being. Like local public health workers, they’re acknowledging the relatively high rates of child abuse and other adverse childhood experiences suffered by Spokane County residents and striving to counteract the effects that researchers have found follow kids into adulthood.

Robin Karr-Morse, a Portland-based therapist and author of two books about how trauma can hurt a child’s brain development, will speak Wednesday at the Spokane Convention Center as part of Our Kids, Our Business (registration is closed). She’ll likely be preaching to at least a few members of her own choir. Educators, people who work in public health and others in the county have taken up adverse childhood experiences, or ACEs, and the trauma that can result as a major theme – a new lens through which to view old problems.

Much of the work has been influenced by the Area Health Education Center, part of Washington State University Extension and located on the WSU-Spokane campus. The center has received funding from the federal and state governments and the Bill and Melinda Gates Foundation.

What researchers have learned about the prevalence of adverse childhood experiences amounts to a “tremendous call to action,” said Chris Blodgett, the center’s director.

“If this was a virus, we would have declared a public health emergency, given what we know about the level of exposure and the level of the consequences that follow from ACEs,” he said.

Conservatively, he said, 1 in 4 people in the U.S. has a high enough ACE “score” that, “where it’s not a guarantee that they’re going to develop problems, it’s certainly one of the clearest risk factors that we can point to.”

Landmark study

The work largely stems from a 1998 study of 17,000 people, generally middle to upper-middle class, in the Kaiser Permanente Health Plan in San Diego. The study found strong connections between abuse, neglect or other traumatic events during childhood and serious health problems in adulthood.

At the start of the 1990s, scientists knew that some people – smokers, alcohol abusers, the severely obese, people with a lot of sex partners – were at higher risk for becoming sick or disabled or dying early. It was also known that those risk factors were not distributed randomly in the population: Some people were more likely to put their own health at risk.

The San Diego study asked why. Led by Drs. Vincent Felitti and Robert Anda, the Adverse Childhood Experience Study found a strong relationship between participants’ history of childhood abuse or household dysfunction and risk factors for leading causes of death in adults. The more adverse events in your childhood, the greater your likelihood for disease.

The groundbreaking study has been followed by more major findings related to adverse childhood experiences and health problems, including autoimmune diseases, heart disease, prescription drug use, depression and liver disease.

It’s also been followed by more questions about what, exactly, happens in children’s developing brains as a result of abuse or other adverse experiences. Researchers use the term “complex trauma” to describe the lasting effects of psychological and physiological “adaptations” children make as they try to cope with abuse, neglect or other adversities.

After we’re born, our brains develop sequentially, WSU’s Blodgett said. Guided by our experiences, behavior is built from the lowest part of our brains to the highest.

In some people exposed to adverse childhood experiences, part of the lower, limbic system that monitors for safety gets distorted: If you’re persistently unsafe, you don’t learn to know when you are safe. And essentially, Blodgett said, the higher parts of your brain that control decision-making, reasoning and problem-solving don’t get engaged. That makes it difficult to learn.

‘Needs are growing’

Bad things happen to a lot of children in Spokane County.

Modeling their research on the 1998 study led by Anda and Felitti, Blodgett and other WSU researchers did a 2010 study of 2,101 children at 10 elementary schools in the Spokane area. They sought to learn the prevalence of significantly adverse events in the children’s lives and whether there was a correlation between those events and academic and health problems.

A person’s ACE score is a measure of how many adverse experiences they’d had.

Forty-five percent of the children in Spokane had experienced at least one significantly adverse event, such as violence, homelessness, the incarceration of a family member or substance abuse in the family. Twelve percent experienced three or more adverse events, according to the research. Controlled for other factors, kids with ACE scores of 3 or higher were six times more likely to have severe behavior problems at school. They were 3.9 times as likely to frequently report poor health.

Among other measures of potentially traumatic events suffered by Spokane County residents:

• Reports of child abuse rose significantly in Spokane County from 2007 to 2011, to 5,264 victims in 2011. (Children were counted more than once if they were reported as a victim more than once.) That translated to a rate of 48.1 children per 1,000, compared with the statewide rate of 33.7 per 1,000, said Elaine Conley, director of the Community and Family Services programs at the Spokane Regional Health District.

• In 2010, 45.9 percent of women ages 18 to 44 in Spokane County had an ACE score of 4 to 8, considered high, Conley said. That’s compared with 33.5 percent scoring high in Washington overall.

Children who’ve experienced abuse or neglect often come to school angry or tired or with trust issues, said Beverly Lund, principal at Spokane’s Whitman Elementary School, which also is working with the WSU center.

“We had a couple of kids who were living in a truck at Wal-Mart, and they used the Dumpster for a restroom,” she said. “They were seen panhandling and begging for food at McDonald’s. Those are issues of just safety and security. And when that’s not taken care of for you, you have a hard time relaxing and learning how to do addition and subtraction and multiplication and comprehend the story you’re reading.”

Lund said one way to deal with trauma is to put mental health counselors in schools. Realistically, though, “our needs are growing so exponentially that a mental health counselor won’t ever meet the need that’s existing in our classrooms,” she said.

Because they’ve learned about how trauma affects children, adults at Whitman are less likely to be surprised by kids’ behavior and more likely to recognize early on – and defuse – problems that will impede learning.

“We as a system need to be able to deal with the issues of trauma so that we can keep kids here, keep them in the classroom, help them feel supported, help them build their resilience,” Lund said.

Lauren Waterbury’s third-grade class is doing Sugars and Salts, a weekly ritual in which the students sit in a circle with their teacher and relate two recent life events each: two goods, two bads or one of each. They’re at Otis Orchards, a few minutes after the start of the school day.

There’s a dog hit by a car, a bloody nose, happiness over a dad’s upcoming visit to a mom’s house.

The students are good at recognizing the gray parts of life, that some sugars are salty, and some salts sweet. One student announces she has one sugar and one sugar that turns into a salt. First, her mother’s wedding would take place in a fun location. Second, she got to see her father four times – but he’d be going away soon. Waterbury cut the girl off when she mentioned drinking as a source of her father’s problems. Some things should be shared privately. But the girl was welcome to talk to her anytime.

It’s normal that some students relate superficial news while others raise intense topics, Waterbury said later. “It lets me know who I need to check in with,” she said.

Inquisitiveness – an effort to notice when a child is troubled and ask why – is an important part of trauma-based principles, said Melissa Charbonneau, a public health nurse in Weaving Bright Futures, a program that puts nurses in schools to work with children and families who’ve suffered adverse childhood experiences.

It’s a way of looking at and interacting with kids. Behavior that seems bizarre to adults may be a child’s best attempt to protect himself.

A hypothetical example: A student who calls his teacher a bad name might ordinarily have been sent to the principal’s office and maybe suspended. A trauma-trained teacher would more likely direct him to stay in a designated spot in the classroom for a while. She might follow up with a conversation to root out the cause of his behavior, Charbonneau said: “ ‘What’s going on today, Johnny?’ instead of ‘You’re out of here.’ ”

That might be followed with a safety plan. Maybe the boy gets a card to hold up when he feels like he’s losing control and needs a break.

Said Savall: “It’s always about trying to help, instead of ‘Get them away from me.’ I don’t know how else to explain that, and that sounds terrible. But teachers do get that way. Unless you can look at a child through compassion, the naughtiest kid is going to drive you crazy.”

At Otis Orchards, Savall and the staff have restructured the daily schoolwide schedule with trauma in mind, starting with the morning-greeting routine and moving into 15 minutes of “Otis time” at the start of the day, when students can meet individually with teachers and each other.

There’s a “zero voices” rule in the halls, so classes passing by don’t disturb kids in other classes. Office staffers no longer interrupt classes via intercom to relate messages from parents to students about changed after-school plans.

“We used to interrupt classes 10 times in the afternoon,” Savall said. “We’d lose these kids for the last hour of the day.”

Because kids with trauma can be thrown off by the unknown, each class’s daily schedule is posted in the classroom; for some children, teachers attach personalized schedules to their desks. Savall delivered a presentation on complex trauma recently to bus drivers serving her school.

“If (children with trauma) have one person or one place in their life that’s going to support them and where they feel safe, they have a much better chance of turning out OK,” she said. “Plus, that activates that part of the brain that has not been stimulated much. … We’re hoping to build that part of the brain up.”

The Area Health Education Center staff has trained about 16,000 people on trauma-based techniques for working with children, including teachers, juvenile justice workers, social workers and health care workers, most of them in Washington.

They’re not trying to figure out how to prevent child abuse, mental illness, suicide or parents being sent to jail. Preventing bad things from happening to children is not a “short-term, high-probability win,” Blodgett said.

Instead, they’re learning and teaching methods for helping kids learn despite the chaos in their lives and, sometimes, their brains. And they’re focusing on the fact that while some children grow into adults whose adversities negatively affect the rest of their lives, others seem to overcome them. What makes the difference, they say, is what they call resilience.

And if kids aren’t building that at home, Blodgett said, they can build it at school or in their neighborhoods or in an after-school program.

“What we think is that once those (bad) things have happened, setting up the circumstances where kids can recover and repair from those things that have happened to them is a realistic goal,” he said.

The efforts extend beyond schools.

A Spokane Regional Health District program called Neighborhoods Matter aims to nurture relationships among residents. Its “community cafés” for residents in the East Central neighborhood have sparked neighborhood cleanups, an audit of broken streetlights and activism to restrict alcohol sales near their homes.

The Weaving Bright Futures program that puts nurses in schools was recently named a “promising practice” by the National Association of County and City Health Officials.

ACEs and complex trauma get a lot of attention at the agency, because the health effects of traumatic events on children’s brains are overwhelming, said Conley, of the health district.

“I mean, you get pertussis – not that that’s a good thing, but chances are you’re going to be over it in two weeks, three weeks, and you’re going to move on with your life,” Conley said. “That’s not the case with complex trauma. The impact stays with you many times over a lifetime.”

The WSU researchers are working on a study, to be completed next spring, comparing the six elementary schools they’re working with against six others. They aim to learn whether their interventions are changing disciplinary practices, special education referrals, academic performance and other measures.

As a “hard-nosed science guy,” Blodgett said, he’s hesitant to place his faith entirely in trauma-based techniques until he sees the numbers.

On the other hand, he said, the anecdotal evidence is compelling.

Savall, at Otis Orchards, said she credits her school’s trauma-based efforts with its School of Distinction awards – it received its third in a row this year – recognizing schools in the state that make the greatest academic gains. In 2009, it also received an Apple Achievement Award, which came with $25,000 for construction.

Whitman’s Principal Lund said she believes the techniques are also making a difference at Whitman.

“I see it in the kids,” she said.


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