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"Agents of Progress: Schools and Child Traumatic Stress,"

by Mary Kelly Persyn October-December 2016 issue of Poverty & Race

Introduction

What’s wrong with you?
So often, this is the question that K-12 students encounter at school in response to their misconduct. School staff members assume that the student’s actions are the product of a conscious desire to rebel and disrupt. But researchers who study child trauma and early adversity present a very different explanation. What if the physiological and neurological effects of child trauma explain at least some of the behaviors that schools see? What if the appropriate question for many of these kids has little do with what’s “wrong” with them, but rather finds the etiology of their actions in the traumas they have suffered?

What happened to you?
How much would change if this were the question that schools asked kids? In what follows, I examine this question by exploring child trauma, considering how it becomes visible in schools, and examining some possible pathways for change.

What is child trauma, and how does it impact kids and adults?

Child trauma encompasses several concepts. Acute traumatic events are singularities involving serious injury to self or witnessing serious injury to or death of another person. Threats of imminent danger so grave that they overwhelm the child are also in this category. Chronic traumatic situations involve continuing physical, sexual, or emotional abuse, domestic violence, and war and other political violence. Such traumas can lead to the development of child traumatic stress if the events overwhelm the child’s ability to cope.

Adverse Childhood Experiences, or ACEs, are a category of child trauma denoting ten different types of experiences that can harm child health and development, with permanent effects. This concept originated in a 1998 study conducted by Kaiser Permanente in cooperation with the federal Centers for Disease Control. (“About the Kaiser-ACE Study,” CDC). The study, performed on a group of largely Caucasian, largely college-educated adults, surveyed their exposure to adverse experiences as children and then measured a variety of health indicators. (As discussed infra, researchers later added other Urban Indicators to account for the experiences of youth living in urban settings.) The original 10 events were emotional, physical, or sexual abuse; physical or emotional neglect; witnessing domestic violence; parental separation or divorce; and living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.

In a result that has since been replicated and expanded, the ACEs study found that ACEs are remarkably prevalent, they are universal, and four or more exposures lead to greatly increased lifetime risk of serious health problems and early mortality. Examples include significantly greater risk of depression, suicidality, alcoholism, and COPD. Researchers believe that on average, people who suffer four or more ACEs without appropriate intervention and treatment die 20 years earlier than those with no ACEs in their history.

In the years since the first ACEs study, researchers have expanded our understanding of how the body’s stress pathways affect health. Stress is not necessarily problematic. In fact, “positive stress” is fundamental to healthy development. But toxic stress, characterized by “prolonged or frequent activation of the stress response” without returning to homeostasis, can cause dysregulation of the body’s neuroendocrine immune circuitry, which ultimately causes changes in brain architecture and organ systems. (Bucci 2016.) It’s very important to understand that toxic stress doesn’t implicate only psychological responses. It triggers a biological phenomenon. Consistently elevated stress hormones affect key areas in the brain, including the amygdala, hippocampus, and prefrontal cortex. These changes alter and erode key behaviors like executive functioning, memory, and emotions. Indeed, for some, “bad behavior may simply be a biological response to the grinding torture of life below the poverty line.” (Keller 2016)

Further research has also expanded beyond the original study cohort, which was made up primarily of white, middle-class, highly educated people. One of the first studies to focus on an urban population was directed by the Institute for Safe Families, which formed the ACE Task Force in 2012 in order to study ACEs in Philadelphia. The participants in ISF’s survey were 44% white and 43% Black; 42% had a high school education (or some high school).

The study found that “traditional” ACEs occurred at a higher rate than found in previous studies, and also measured the prevalence of other stressors. The survey found that 33.2% of Philadelphia adults experienced emotional abuse and 35% experienced physical abuse during childhood; about 35% grew up in a house with a substance-abusing member; 24% lived with a person who was mentally ill; and 13% counted an incarcerated person among their household. Overall, 68% experienced at least one of the original nine ACEs.

Beyond these ACEs, the Philadelphia ACE Task Force developed an urban ACE module to study how urban stressors affect physical and mental health. The additional Urban ACE Indicators include experiencing racism; witnessing violence; living in an unsafe neighborhood; living in foster care; and experiencing bullying. The behaviors and health outcomes measured included sexual partners, smoking, suicide attempt, substance use, cancer, diabetes, obesity, asthma, and mental illness. Addition of these indicators resulted in a total possible ACE score of 14, rather than the original 9.

The results were striking. Nearly 41% of the survey respondents had witnessed violence while growing up; 35% experienced discrimination based on race or ethnicity; 27% reported feeling unsafe in their neighborhoods during childhood. Overall, 58% experienced at least one of the five Urban Indicators; 81% experienced at least one of the 14 total ACEs; and 45% experienced at least one of the original ACEs and at least one Urban Indicator.

In all, over 37% of the respondents reported four or more ACEs. The equivalent number from the original Kaiser study is 12.5%. Philadelphia residents are nearly three times more likely than Kaiser’s white middle-class cohort to suffer this dangerously high level of adversity. Further, 14% of survey respondents experienced at least one Urban Indicator but zero traditional ACEs—meaning that these respondents experienced early adversity that never would have shown up in a traditional ACEs survey. (As the ISF notes, these results may not generalize to other urban areas. Further, the data are preliminary and need further refinement to account for possible confounding of variables. However, at a minimum, the study indicates that further research on Urban Indicators is necessary to explore these apparent disparities, including how ACEs vary by gender, race, and ZIP code.)

The overlay of the Philadelphia survey results onto city zip codes demonstrates the correlation of neighborhood poverty to the highest levels of ACE exposure. U.S. Census data reveals a further intersection with race; of the six zip codes with the highest ACE scores, four have a population at least 50% African American and two are 80% African American and over (Wade, 2016).
The Philadelphia data appear to show a strong correlation between race, poverty, and levels of ACEs exposure that are high enough to pose very significant threats to the physical and mental health of affected residents.

How does trauma manifest in schools, with what typical result?

We know that ACEs are prevalent and universal. Recent research appears to show that ACEs exposure is more severe for urban populations and especially for people of color and people living in poverty. What does this mean for children?

First, we know that high ACEs exposure negatively impacts child development. The resulting physiological changes can make cognition and sustained focus more difficult and interrupt the learning process. A report describing representative experiences of the general Head Start population in Spokane, Washington found that, among children three to four years old at the time of the screening, ACEs exposure is very high. Further, as ACEs exposure increases, teachers and parents report risks to child development. These results “suggest that children with higher ACEs not only experience lower development assets (attachment quality) but increased rates of behavioral concerns” (Blodgett, 2014). The study found that in this population, high ACEs were generational; 63% of parents and 40% of three to four year old children had experienced three or more, where three ACEs is the threshold for significant health and social risks.
In the context of school performance, these results are especially concerning because of the strong correlation between ACEs exposure and below-average measures of social and cognitive development (Id. at 3). Specifically, high ACEs exposure in very young children correlates to difficulties with school readiness, particularly social emotional adjustment and cognitive skills (Id. at 10).

The results appear borne out for older children in another study performed among public elementary school children in Spokane, Washington. Dr. Chris Blodgett and his investigators had school staff interview children regarding academic problems, health concerns, and adverse events. (Spokane Childhood ACEs Study) Among the academic problems were not meeting grade level expectations in one or more subject areas, attendance problems that interfere with learning, and school behavior problems that interfere with learning. The adverse events measured did not precisely duplicate traditional ACEs or Urban Indicators, but contained similar exposures.

In the context of this study, Dr. Blodgett and his researchers found that exposure to even one ACE increases the risk of poor outcomes. Further, the review confirmed the dose-response relationship between ACEs exposure and child development risk: the more ACEs, the higher the risk (Id. at 2). The table of odds ratios compiled by researchers highlights the particularly sharp rise in severe school behavior concerns in response to ACEs exposure, especially in response to three or more. It also highlights the greatly increased risk of severe attendance problems, with a spike between two ACE exposures (2.6) and three or more (4.9). This is concerning because chronic absence can severely damage learning and ability to progress toward a diploma. (For example, in California, researchers found that 73% of students who were chronically absent in kindergarten and first grade are unable to meet California standards for English Language Arts once they get to the third grade) (CA AG 2016).

Researchers concluded that adverse childhood events should be a focus for school-based risk reduction efforts and that “attending to ACE exposure in children may be the most powerful predictor of risk for school to attend compared to other common school risk indicators” (Spokane Study at 4).

Second, as the Spokane Study’s findings on behavioral issues and other studies appear to indicate, ACEs exposure can trigger and exacerbate symptoms that lead to disciplinary difficulty in school for children who have suffered trauma. We know that trauma and its aftermath can cause symptoms including attention deficits, emotional dysregulation, and oppositional behaviors (American Academy of Pediatrics 2014). Because traumatized children have learned to evaluate their surroundings for danger, the classroom setting can “sabotage their ability to remain calm and regulate their behavior in a classroom” (Trauma Learning Initiative). Because traumatized children have great difficulty in interpreting social cues and communicating appropriately about their feelings, their behavior—whether acting out or “zoning out”—is ripe for misinterpretation by teachers, which can lead to significant difficulties for children (Id.). Traumatized children may distrust teachers and peers, and may be more aggressive in their relations with others. These characteristics of traumatized children may make them more likely to be subject to the very discipline—up to and including exclusionary practices like suspension and expulsion—that are most likely to re-traumatize them (Education Law Center 2014). (As noted below, the role of discriminatory school discipline practices is important to acknowledge here as well.)

The impact of ACEs on student learning is of special concern because poor students and students of color are overrepresented among the population of students with three or more ACEs (Keller 2016). Poor students perform less well at school not only because they attend schools with high turnover, high student-to-teacher ratios, and fewer resources at home (critical as those issues are): they are also more likely to have a high ACE score (Id.). Further, low-income communities are disproportionately comprised of minority persons (Id.). The burden of ACEs is borne, in large part, by those children least able to access the resources and support structures that could help them build resilience to traumatic experiences. (Center for Youth Wellness CEO and ACEs expert Dr. Nadine Burke Harris, a pediatrician practicing in San Francisco, identifies several resources that help children build resilience to toxic stress. These include educating and empowering caregivers about ACEs and the community resources available to them; engaging families in Child-Parent Psychotherapy; enabling families to access healthy food and exercise; and using biofeedback to educate children about their own stress responses)(Harris 2014).

The high—and disproportionate—rate of suspensions of poor children and children of color may be another indicator of the heavy ACEs burden that these children bear. Recent figures indicate that 16% of African- American students, 7% of Latino students, and 4%-5% of white students were suspended during the 2009-2010 and 2011-2012 school years (Losen 2015; Flannery 2015). In 2010, over 70% of students arrested at school or referred to law enforcement were African American or Latino (Kirwan 2014). Notably, while ACEs exposure may be a partial explanation for the disparity, the Kirwan Institute argues that the differential suspension rates are due in part to the forces of implicit bias. Id. at 2-3. It is entirely possible that both forces are at work in this phenomenon. These facts matter because of the impact that suspensions and involvement with law enforcement have on a student’s chances of long-term success: a suspension is the number-one predictor of whether students will drop out of school and experience unemployment, reliance on social welfare programs, and imprisonment (Flannery at 3-4).

ACEs research appears to show that children of color and children living in poverty suffer much higher rates of exposure to ACEs and also suffer higher rates of exclusion from the classroom. Research continues on who these children are, how they fare in the classroom, and what interventions will be most useful for them.

Two interesting developments out of California illustrate possible future pathways for action to transform the way that schools perceive and address trauma and toxic stress among their students.

The Compton USD lawsuit

The Compton Unified School District, located in Los Angeles, is one of the poorest and most challenged school districts in the state. In July 2015, plaintiff students and teachers filed suit against the District, alleging that the District had failed to address the students’ trauma symptoms and, instead, had engaged in practices that pushed them out of school. The plaintiffs further argued that these trauma symptoms qualified as a disability under the Americans with Disabilities Act; if true, the district was required by federal law to address and mitigate the consequences of the students’ exposure to various types of trauma.

In September 2015, the trial court denied the District’s motion to dismiss, finding—crucially—that the plaintiffs’ allegations could qualify as claims under the Americans with Disabilities Act (“ADA”). (Materials available at Trauma and Learning website.) The judge did not rule that claims of untreated trauma made against school districts would qualify under the ADA as a physical impairment for the purposes of the Act, but he refused to strike them categorically—and this was a big win. The allegations stated in the complaint cover many of the Urban Indicators discussed above along with traditional ACEs, claiming that these events profoundly affected plaintiffs’ well-being and ability to learn. These factors are at the heart of the claim that untreated trauma leads to conditions that qualify as disabilities under the ADA.

The parties are currently in settlement talks. The ultimate agreement regarding the District’s responsibility to alleviate trauma symptoms could be a bellwether for other school districts across the state and nation.

The example of SFUSD

Many school districts are working on responding to trauma among their students by integrating trauma-responsive practices, becoming trauma sensitive schools, developing restorative justice techniques, and other approaches. (See, e.g., Trauma Sensitive Schools website.) The San Francisco Unified School District’s approach, which relies primarily on its Safe and Supportive Schools programming, has experienced significant success over the last seven years in consistently reducing suspensions and including Social Emotional Learning Indicators on K-5 report cards (SFUSD 2016). (The District acknowledges it needs continued work on school climate, cultural competence, and classroom management, due to poorer scores in referrals and chronic absenteeism.)
A key part of SFUSD’s shift away from retributive practices that can re-traumatize students is its Restorative Practices Resolution, passed in 2009. The Resolution has four parts:

1. “The Paradigm Shift away from Punishment.” The District moved away from “Zero Tolerance” and toward community building and social skill development.

2. “The Shift to doing things “With” People, instead of “To” or “For” People.” This principle encourages schools to work with staff and students in a supportive and less controlling way.

3. “We are Advocates for Social Justice.” The District acknowledged the significant role played by race and committed the schools and staff to be “agents of progress in the struggle for Social Justice.”

4. “We consciously and proactively build positive school communities.” The District committed to proactive activities with students and school communities throughout the year.

The District believes that the Resolution may be the biggest factor in the significant decline in suspensions in the District since 2011.

Conclusion

As our understanding of child trauma and toxic stress crystallizes, schools have a unique opportunity to view student conduct through a trauma lens and consider whether neurobiological and physiological responses to toxic stress have an undue influence over students’ actions. The purpose is not to disregard the conduct, nor to avoid confronting problems of bias in school discipline, but rather to make use of the conduct as a red flag for psychological and physiological distress. Through the use of restorative justice and other innovative techniques, schools can ask not “what is wrong with you?” but rather “what happened to you?” These questions are of particularly acute importance to poor students of color, who, due to this intersection of identities, carry the heaviest burden of stress. Easing that physiological and emotional burden will go far to support these students and promote their success.

Resources

About the Kaiser-ACE Study, available at http://www.cdc.gov/violenceprevention/acestudy/about.html.

Adverse Childhood Experience and Developmental Risk in Elementary Schoolchildren, Spokane Childhood ACEs Study at 1 (n.d.) (“Spokane Study”), available at http://ext100.wsu.edu/cafru/wp-content/uploads/sites/65/2015/02/Adverse-Childhood-Experience-and-Developmental-Risk-in-Elementary-Schoolchildren-Research-Briefx.pdf.

American Academy of Pediatrics, Adverse Childhood Experiences and the Lifelong Consequences of Trauma at 3 (2014), available at https://www.aap.org/en-us/Documents/ttb_aces_consequences.pdf.

Trauma Learning Policy Initiative, Helping Traumatized Children Learn, The Problem: Impact, available at https://traumasensitiveschools.org/trauma-and-learning/the-problem-impact/.

Christopher Blodgett, ACEs in Head Start Children and Impact on Development at 1, 3, 10 (2014) (manuscript in preparation), available at http://ext100.wsu.edu/cafru/wp-content/uploads/sites/65/2015/03/ACEs-in-Head-Start-Children-and-Impact-on-Development-1-14.pdf

Monica Bucci et al., Toxic Stress in Children and Adolescents, Advances in Pediatrics 63 (2016) 403-428, 409.

Education Law Center, Unlocking the Door to Learning: Trauma-Informed Classrooms & Transformational Schools at 4 (Dec. 2014), available at http://www.elc-pa.org/wp-content/uploads/2015/06/Trauma-Informed-in-Schools-Classrooms-FINAL-December2014-2.pdf.

In School, On Track: Attorney General’s 2016 Report on California’s Elementary School Truancy & Absenteeism Crisis at 3 (2016).

Mary Ellen Flannery, The School-To-Prison Pipeline: Time to Shut it Down, NEA Today at 3-4, 6 (Jan. 5, 2015), available at http://neatoday.org/2015/01/05/school-prison-pipeline-time-shut/.

Dr. Nadine Burke Harris, The Chronic Stress of Poverty: Toxic to Children, The Shriver Report (Jan. 12, 2014), available at http://shriverreport.org/the-chronic-stress-of-poverty-toxic-to-children-nadine-burke-harris/. These resources are expensive and for the most part not covered by Medicaid.

Jared Keller, Unhelpful Punishment, Slate (May 13, 2016), available at http://www.slate.com/articles/health_and_science/medical_examiner/2016/05/the_stress_low_income_kids_experience_affects_their_brains_biologically.html.

Kirwan Institute for the Study of Race and Ethnicity, Racial Disproportionality in School Discipline: Implicit Bias is Heavily Implicated, at 1 (Feb. 2014), available at http://kirwaninstitute.osu.edu/wp-content/uploads/2014/02/racial-disproportionality-schools-02.pdf.

Daniel Losen et al., The Center for Civil Rights Remedies, Are We Closing the School Discipline Gap? at 5 (Feb. 2015), available at https://www.civilrightsproject.ucla.edu/resources/projects/center-for-civil-rights-remedies/school-to-prison-folder/federal-reports/are-we-closing-the-school-discipline-gap/AreWeClosingTheSchoolDiscipline Gap_FINAL221.pdf.

The Philadelphia Adverse Childhood Experiences (ACEs) Project: The Urban ACE Study, slide 16 (comparing ACEs in the Philadelphia study to those in the Kaiser study), available at http://www.instituteforsafefamilies.org/sites/default/files/isfFiles/Urban%20Aces%20Study%20SlideShow%20version%2011-19-13.pdf.

SFUSD, Safe and Supportive Schools Report at 4 (Sept. 2016).

Trauma and Learning website (key documents from the Compton lawsuit), www.traumaandlearning.org.

Trauma Sensitive Schools, https://traumasensitiveschools.org.

Roy Wade, Jr., Childhood Stress and Urban Poverty: The Impact of ACEs on Health, slide 37 (overlay map), available at http://pa-elic.org/wp-content/uploads/2016/05/RoyWadepresentationforwebsite.pdf.

Mary Kelly Persyn is the inaugural director of the Hanna Institute at the Hanna Boys Center in Sonoma, California.
mkpersyn@hannacenter.org
 
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