Doctor’s Notes: At this Preschool for Traumatized Kids, Emotional Care Comes First, Then Academics

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This article was originally published on California Health Report on 7/10/2018.

Reggie, now 5, was exposed to methamphetamines in utero and, after he was born, his biological mother wasn’t able to care for him. When he was 4-weeks-old, I was his doctor in the foster-care clinic at Harbor-UCLA Medical Center. He was adopted by one of my pediatric colleagues, Amy Huang, and her husband, Daniel. Because Reggie is a minor, his and his parents’ names have been changed.

“He was the best baby, no withdrawals, no terrible twos,” Amy Huang said. “We thought he had escaped the meth-effects.”

But, unfortunately, that wasn’t the case.

In January, when Reggie returned to preschool after winter vacation, he started having extreme behaviors. He became defiant and aggressive. He was biting, hitting strangers and at times getting on all fours and acting like an animal. His parents were frustrated and worried that the problems were related to his drug exposure.

The effects of methamphetamines on infants in the womb run a wide spectrum, from mild learning problems to significant impairment of brain function. These infants may be born premature, have low birth weight or suffer withdrawals causing jitteriness, irritability and poor feeding. In addition, meth-addicted mothers often have poor health and may use other substances such as marijuana, tobacco, alcohol and cocaine. All of these can have negative effects on the infant’s development, as well as the mother’s ability to parent.

ChrisAnna Mink is a pediatrician who practices in South Los Angeles.

Researchers have shown that children who were meth-exposed in utero have difficulties with their brain’s executive function, which is the central command for organizing thoughts, planning and learning. These children also have an increased risk of disruptive behaviors and attention deficit/hyperactivity disorder (ADHD), as well as depression, anxiety and other mental illnesses, when compared to non-exposed peers. Some of these problems don’t become obvious until the cognitive and behavioral demands of a classroom.

By spring, Reggie’s behavior was spiraling out of control and his preschool teachers couldn’t cope with him. The Huangs took him out of that school but didn’t know where to turn.

I recommended Children’s Institute Inc, as did some other friends with an adopted child who had also been exposed to drugs. I was familiar with the Institute’s therapeutic preschool called Day Treatment Intensive, DTI. Over the past 12 years, I have referred many children with behavioral difficulties due to drug exposure, abuse, neglect and other psychological traumas.

DTI “looks like a regular preschool,” said Nicole Fauscette, a licensed family therapist and supervisor of the program, but it offers real-time, individual therapy. First, DTI focuses on mental health, in a supportive and developmentally appropriate preschool setting. The school adds in academics as the children are ready.

The Children’s Institute building on Harbor-UCLA’s campus is surrounded by playgrounds. The inside is decorated in lively colors, and it’s neatly cluttered with toys and children. It looks like Crayola designed a home inviting visitors to come play.

Children ages 2½ to 5 are eligible. Many have been expelled from regular preschool. DTI has space for 12 children and classrooms have, on average, one staff member for every two kids. Referrals come from child protective services, pediatricians, Head Start, internal mental health programs and community mental health agencies.

DTI is one of less than a dozen such specialized programs in Los Angeles County, which is home to nearly 330,000 children younger than five. About 20 percent of those kids live in poverty and most have experienced adversity. The need far exceeds the slots available.

“Therapeutic preschool uses the neuro-sequential model,” said Jesus Parra, the regional director for clinical services for Children’s Institute. This approach provides a framework for helping a child, keeping in mind his or her trauma history, developmental stage and current ability to function.

“We help the kids get to a place where they can regulate their behaviors, increase their attention (and) their tolerance of frustration, and better navigate peer and adult relationships,” said Fauscette. The goal is to help the children achieve emotional stability, so they’ll be ready for a traditional learning environment.

The staff and volunteers at DTI are chosen in part because of their temperament and ability to regulate their own emotions. These qualities are as valued as their education, though most have backgrounds in child development, psychology or mental health.

“An adult in control of their emotions helps children who are not in control of theirs,” said Parra, who leads some of the staff trainings.

The program aims, Parra said, for “the parents to fall in love with their child again.”

Reggie started at DTI in early May. The teachers observed that when he behaves like a dinosaur or other animal, it is because he is feeling anxious and frightened. In this way, they reason, he is attempting to defend himself against the danger he perceives. So, instead of punishing him for disobeying, Reggie’s teachers approach him calmly and help him address his anxiety.

In the last few months, Reggie has made progress learning to use words—and not aggression—to express his emotions.

The Huangs have already noticed a change. The teachers “were able to describe to us how Reggie interprets his world,” Daniel Huang said. “It’s helping—him and me.”

Pediatrician ChrisAnna Mink writes the bimonthly Doctor’s Notes column on Cal Health Report’s children’s health.

Doctor’s Notes: Head Start Offers Better Beginnings for School, Resilience for Life

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This article was originally published on California Health Report on 6/22/2018.

Colleen Kraft was in preschool when she heard something that helped chart the course of her life.

“I remember that my Head Start teacher told me that I was so smart I should be a doctor,” Kraft told me in a recent conversation. She’s now a pediatrician and current president of the American Academy of Pediatrics. Kraft is also a graduate of the 1965 inaugural Head Start class, which she proudly proclaims in the first line of her bio.

Head Start and Early Head Start programs provide services to poor children and their families in three core areas: learning, health and family wellbeing. Early Head Start provides services for infants from pregnancy until age 3 and Head Start is for children ages 3 and 4. Both programs were established as part of the War on Poverty under President Lyndon Johnson, with the goal of preparing low-income preschoolers for kindergarten.

Children from families that qualify for public assistance, foster children and homeless children are eligible for the programs. Some children with family incomes above the poverty level, including some disabled children, also qualify for Head Start. The programs even offer assistance to disadvantaged pregnant women through Early Head Start programs that emphasize the importance of a healthy pregnancy, parenting skills, child development and early learning.

ChrisAnna Mink is a pediatrician who practices in South Los Angeles.

The annual federal budget for Head Start programs is just above $9.5 billion and a significant portion of that funding – about 11 percent – goes to California, which serves nearly 100,000 children and pregnant women.

Poverty is associated with lower academic performance for reasons related to the child, the household and the community. Low-income parents often have attained less education, are less involved with learning activities with their children and preoccupied with the ongoing stress of meeting their family’s basic needs for food and shelter. As a result, their children hear fewer words, have poorer health and nutrition, miss more school days, and face more struggles with attention and impulsivity compared to more affluent peers. Impoverished children are also more likely to live in neighborhoods with fewer resources such as libraries and grocery stores.

Research has shown the benefits of the Head Start programs for learning, behavior, health and parenting skills. Head Start students scored better than a control group for cognitive and social-emotional development, had higher rates of immunizations, healthier weights and less problematic behaviors. A 2016 study showed that Head Start children were more likely to graduate from high school, attend college and get a post-secondary degree, license or certification.

“I went to Head Start by Watts Tower,” said Nancy Munoz, mother of Armando, “I always knew Head Start was important and I wanted Armando to go.” Now 3, Armando just completed his first year in Early Head Start.

Munoz is a single mother who works full-time as a bail bond agent, but she couldn’t afford most preschools. She learned about the Head Start classes at Children’s Institute, Inc., in her neighborhood in Watts, an impoverished area in Los Angeles. As a pediatrician in South Los Angeles, I work closely with the organization’s child development and mental health experts, who introduced me to Munoz and Armando at their Watts center.

Children’s Institute serves nearly 2,000 children in its Early Childhood Education programs, including Head Start, Early Head Start and home-based programs, throughout the poorest communities in Los Angeles. Almost 90 percent of the participants are Latino and African American.

“We can do all we want in the classroom, but if the kids still have health or mental health issues or the families aren’t ready, then the kids aren’t ready.”  said Justine Lawrence, vice president of early childhood programs at the organization.

Kids growing up in poverty are also at risk for adverse childhood experiences, called ACEs. ACEs include traumatic events such as abuse, homelessness, hunger, witnessing violence and separation from a parent. Children who are hungry, frightened or anxious can’t learn as well.

As part of school readiness, Head Start programs help nurture resilience for disadvantaged kids with a history of ACEs. Resilience is defined as good mental and physical health despite adversity—in other words, the ability to withstand and recover from adversities.

After years of working with low-income families, I’ve come to believe that combating ACEs contributes as much to a child’s academic success as learning the ABCs.

Munoz contended with multiple ACEs, including time in the foster care system, because her mother struggled with mental illness and her father with substance abuse. At 16, she and her siblings were taken in by their aunt. She is grateful to Head Start and her tia for her survival.

Munoz reads to Armando’s class once a week and credits Head Start for helping her be a “more present” parent. Munoz and Armando haven’t had an easy beginning, but “having him in Head Start is one thing to make his life easier,” she said.

“I refer families to Head Start all the time,” said Kraft. “I use it as a mechanism to support kids in unstable situations.”

Like Kraft, I also refer children to Head Start. Most of my patients are low-income and many have had ACEs. I know their parents need better coping skills. Overweight toddlers need more activity and their parents may need to learn about nutrition. I turn to the program to help children who are smart and others who are struggling because they all need the stimulation. Low-income families need more resources and the programs provide key supports. That’s why Head Start is one of my weapons in the War on Poverty. It changes lives, one kid at a time.

What Are Children Telling Us?

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It’s National Mental Health Awareness month, and I keep thinking about Antoine because I may have broken his heart.

Years ago I volunteered at a residential treatment center for foster children, in a cottage that housed ten young boys. They were “seriously emotionally disturbed,” the threshold classification for placement in that center. Most had survived multiple foster homes, sometimes punctuated by stays in psych hospitals, only to become “unplaceable” and almost certainly unadoptable.

During my weekly visits, some boys avoided me while others checked out the Pokémon cards or Legos I brought, only to wander off within minutes, endlessly distracted. But Antoine, 11, always sat by me, rapt and loyal. He built plastic cities, or painted his arms in Wonder bread polka dots, or listened to Harry Potter by the hour. Clever, powerful and entirely winning, Antoine had a monk-like focus, even when all hell broke loose in the cottage. He particularly loved an oversized book on the Titanic; we imagined life on every deck, the sound of the ocean, the smells of the boiler room (but never the ending). Antoine and I hung out in a corner of the common room every Tuesday, week after week. In that chaotic place, it was one thing we both could count on.

And then one day he wasn’t there: he had to spend the day in court. Before this third birthday he’d been taken from the custody of his grandmother because she extinguished cigarettes on his body and sexually abused him, but I didn’t know anything about his current status.

Meanwhile, emboldened by Antoine’s absence, 9-year old Shawn grabbed the Titanic book, sat with me for a while and soon lost interest.

The following week Antoine was back, but he refused to speak to me. I asked him why, I joked, I begged, and then gave up. The next week, same thing: wouldn’t look at me, wouldn’t answer, wouldn’t touch anything I left behind for the boys to use. I asked his counselor what was going on, but he was calming a crying boy, inconsolable after losing a basketball game. I finally got Antoine’s attention long enough to apologize for sharing the Titanic book with another kid, but he never, ever spoke to me again. By April, he was gone, transferred to another group home.

What became of that extraordinary child, so keen, so persistent? His stubborn silence told me he was nothing like the other boys, that he was proud, vigilant, in control. Perhaps by sharing my time and his book with the other boy I had betrayed him, like so many others with whom he’d felt just a little bit safe. Who knows how many adults broke him, even after his physical scars healed.

How do children communicate their pain? And are we listening?

One out of five children has a diagnosable mental disorder, and it’s estimated that 80 percent of foster children have significant mental health issues. Quiet kids like Antoine may not advertise their trauma history with antisocial behavior, but former foster youth in general are five times more likely to suffer from post-traumatic stress disorder (PTSD) than the general population, and even exceed the rate for American war veterans.

The effects of trauma, especially complex and repeated trauma experienced by so many young people in foster care, are varied: dissociation, depression, anger and anxiety. Children may lack self-regulation and appear to overreact or underreact. Chronic stress affects cognition and executive functioning, and is a predictor for long-term physical health, as well as substance abuse and other suffering.

In celebration of National Mental Health Awareness month, let’s listen to children, without judgment, and remember how many are exposed to violence, in their homes and in their streets and schools. They are longing to trust, no matter what they say or do.

The National Child Traumatic Stress Network has excellent information and resources. To commemorate national Mental Health Awareness Month, let’s mend hearts, not break them.

 

This article was originally posted to The Huffington Post on 5/15/2017