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Mental health, better schools, and the trauma of violence

Yale Medicine Magazine, 2017 - Spring


How the School of Medicine and community partners work together for a healthier New Haven.

From her window at a downtown check cashing business just off the New Haven Green, Stacy Downer had a front-row seat to her community. Through her interactions with her customers, she saw how they struggled and how hard they worked to get by. “I started to see that things were not right,” she recalls. She could predict when the people who were selling the food, clothes, and shoes she bought on the street outside would come in each month to use the business’ bill paying service. “They would pay $50 here and $50 there, just so they could have $300 in their pocket for the month,” Downer observed. “They needed help.

“I started learning little things that would help me keep money in my pocket, and not always be so stressed out,” she says. “I started helping my customers do the same thing. When they came in, they would give me all their bills, and I started writing budgets for them. Sometimes right there at the window.” Her sharp financial sense led to a promotion to manager, but a downturn in the economy shuttered the check cashing business, and Downer lost her job.

Shortly after, she was recruited by the New Haven Mental Health Outreach for MotherS, or MOMS, Partnership, which links eight government and nonprofit agencies, including the School of Medicine. Housed at the Department of Psychiatry and the Yale Child Study Center, the MOMS Partnership connects mothers to mental health services to help them combat depression.

MOMS is one of many community partnerships that allow the School of Medicine to engage with the New Haven community. Some, like MOMS, help women in need; others, like the Yale Child Study Center’s Comer School Development Program, help children succeed in the public schools. All the School of Medicine’s partnerships link Yale experts with people in the community poised to help others: another, the Child Development-Community Policing Program, partners New Haven police officers and Yale clinicians, who arrive together at crime scenes to counsel children who have witnessed violence. These partnerships loop in a variety of stakeholders to work above and beyond the capacities of traditional institutions, and use innovative approaches to fill gaps in services.

An ambassador for mental health

“We have taken many approaches to address maternal depression in the last decade or more in New Haven, and those approaches weren’t yielding tremendous results in terms of changing outcomes for families,” says Megan V. Smith, M.P.H. ’00, Dr.PH., principal investigator and director of the MOMS Partnership. “The partnership started out of a general recognition that there was a need for innovation in the area of maternal depression and maternal mental health.”

One of those innovations is the position of Community Mental Health Ambassador. Downer, the former check cashing manager, is one of 10 ambassadors, all mothers from the New Haven community who are trained to work side by side with Yale clinicians to provide counseling and other services, including job training and connections with housing. Ambassadors are employed by Yale, as well as by the Clifford Beers Clinic and the New Haven Health Department, both MOMS Partnership members. “We employ mothers from New Haven who might have had experience in a nail salon, or a hair salon, or who have worked in a customer service profession,” says Smith. The job builds on these women’s natural empathy and leadership skills from previous jobs, like Downer’s work helping customers and neighbors with budgeting.

Ambassadors teach mothers vital skills and strategies to manage their stress and depression, find better jobs, and become more effective, less harried parents. They have also been trained to employ such mental health strategies as cognitive behavioral therapy, or CBT, one of the most efficacious treatments for depression, according to Smith. “In CBT, they give mothers concrete examples of the skills we are trying to teach, so they can apply skills that we teach to experiences that mothers may actually have,” says Smith.

When she speaks to women, Downer shares her own experiences raising her children in downtown New Haven. “Before I got the job at the check cashing place, I was homeless. I was living in a shelter, and I was pregnant,” she says. “And there was no help.” Sharing her own story, she says, makes her more effective.

On a winter evening, Downer and a colleague attended a community event at the Wilson Branch of the New Haven Public Library in the Hill neighborhood, a few blocks from the School of Medicine campus. The room around them buzzed with activity: Volunteers helped people prepare tax returns; children ran around; women held a dance class. And a woman approached Downer’s table to find out more about MOMS Partnership services.

Depression is a severe problem for women in distressed communities like the Hill. According to a 2016 report published by the MOMS Partnership, 71 percent of women interviewed in New Haven reported needing help managing sadness. In the Hill neighborhood alone, 87 percent of mothers felt they had poor emotional health. But many fear asking for help. “One of the barriers that prevents women from seeking mental health services is that they are afraid their children may be removed from their care,” says Smith. “That’s a real fear.” There is also a stigma in the community, Smith says, about asking for mental health help.

To remove some of that stigma, MOMS brings their services to places where women may gather, like community events at the library. The program also runs five “hubs” around New Haven at such places as the Stop and Shop on Whalley Avenue and a public school in West Rock. At these dedicated centers for mental health and job training services, the Partnership offers classes on parenting, stress management, and financial health.

So many programs, Downer says, come and go from New Haven without having made any real impact. “Over the years, they have broken down the resolve of moms in the community. They are not trusted,” she says. “I say to the moms, ‘I want you to understand that someone is out here, and they are here for the long haul.’ ”

A partnership that has endured

Starting in the 1960s, James P. Comer, M.D., M.P.H., the Maurice Falk Professor of Child Psychiatry in the Child Study Center, saw that cultural institutions that had sustained black families were eroding and putting children at risk.

“There was a decline in the power of the family and in the church community,” he recalls. “The old corner drugstore gave way to Walgreen’s. The policeman on the beat was no longer on the beat, and he was no longer a friend of your family.”

While some families in the face of racism and poverty were able to create home cultures that protected children and helped them thrive, not all could. Many black children were underperforming in school and getting into trouble. These problems required a new way of thinking that challenged the way institutions connected with their communities. “The schools had that potential that nobody else had,” Comer says. “We needed institutions to change so that they became part of the family, and the family became part of the schools.”

Comer saw that students from poor areas were not lost causes, as public schools had assumed, but had what it takes to be successful in school. What they lacked was the preparation that would move them into readiness. Schools, Comer realized, needed to address six developmental pathways: social-interactive, psychoemotional, ethical, cognitive, linguistic, and physical. The solution was a community partnership—the Comer School Development Program (SDP), a collaboration between the Yale Child Study Center and the public schools of New Haven—that pioneered the idea that children should be taught according to the principles of child development.

During her 25 years in New Haven schools as a teacher and magnet resource coach, and now as a principal of the Brennan-Rogers School, Gail DeBlasio has seen how important it is to understand the tenets of child development to reach children, particularly those who are vulnerable. “I think sometimes we forget as adults that we are better able to compartmentalize our hurt, but as kids, those wounds fester, and they erupt in the classroom and come out as difficult behaviors. We assume it’s a child misbehaving, and not a child in crisis, or a child who has had enough.”

DeBlasio is applying Comer principles at Brennan-Rogers, a low-performing Pre-K through eighth grade magnet school in New Haven’s West Rock neighborhood, where 20 percent of its more than 500 students require special education services. Children often have water bottles at their desks to support their physical development. They take “Brain Breaks” and get up to toss a ball around while shouting out math facts. During daily morning meetings, students talk about problems with other children, or stresses from outside school that might affect their learning. Building from those discussions, students are then asked to mediate disputes between fellow students. Those meetings “brought SDP into the classroom by dealing with children’s psychological and ethical pathways,” says DeBlasio. “Learning how to disagree in an agreeable manner, being able to identify and express what’s bothering them, and learning how to articulate that properly—those are all skills that we take for granted that kids have, but they have to be built.”

As in all Comer schools, Brennan-Rogers has a School Planning and Management Team of administrators, teachers, support staff, and parents to guide the core goals of the school. Comer schools also have two community-centered teams: The Student and Staff Support Team plans interventions around students who are not performing successfully in the classroom. The Parent Team, which is more inclusive than a traditional parent-teacher organization, involves any parent who wishes to develop activities that enrich the school’s social and academic programs.

“The whole notion of bringing the community into the school,” says DeBlasio, “really started with the Comer program.” That notion extends to classrooms, where students have a say in how classrooms are run: At the beginning of each school year, students draft classroom rules. “They are invariably tougher than I would have been,” DeBlasio laughs.

In 1968, Comer and his team initiated the SDP in the two lowest-income and lowest-achieving elementary schools in New Haven, where 70 percent of students’ families were receiving federal assistance. After three years, Comer said, the climate the program aimed to create had taken hold; after seven years, attendance improved, and the number of behavioral problems dropped. By 1979, Comer wrote in a 1988 Scientific American article, fourth-grade students were up to grade level, and by 1984, fourth-graders in both schools ranked third and fourth in New Haven on the Iowa Test of Basic Skills.

The Comer model has since been implemented in more than 1,000 schools in 26 states, the District of Columbia, Trinidad and Tobago, South Africa, England, and Ireland. Twenty-eight New Haven schools still use the Comer model, and most of the district’s 46 schools have had some training with the program.

At Brennan-Rogers, DeBlasio has seen incremental change thanks to the Comer principles. “Our test scores are going up slowly but steadily,” she says. “We still have kids in crisis,” she says, “but we are not going backward. We are moving forward.”

Helping children cope with violence

When children are exposed to violence, a quick response is of the essence: it helps reduce the damaging, lasting effects of witnessing violence and allows the recovery process to begin.

As first on the scene, police officers may also be the first to establish the order and safety that is the first step to a child’s recovery. The officers are there well before mental health and social services professionals can provide crucial early intervention.

Twenty-five years ago, Steven Marans, M.S.W., Ph.D., Harris Professor in the Child Study Center, saw an opportunity to connect clinicians and police officers so that children get the help they need. In 1991, he founded the Child Development-Community Policing (CD-CP) program, a partnership between the Yale Child Study Center and the New Haven Police Department. The program is housed in the Childhood Violent Trauma Center (CVTC) led by Marans. The program’s three goals are to keep children and families safe, provide a sense of security, and offer services to help with recovery.

Children who witness or experience violence are at risk of anxiety disorders, post-traumatic stress disorder (PTSD), alcohol and drug abuse as adolescents, and antisocial behavior. Later in life they may themselves inflict violence on others. “Instead of sitting in our consulting rooms way down the road when kids are already struggling, we reached out to the police,” says Marans. Police, he adds “recognized that they were not going to arrest their way out of the cycle of violence. And they reached out to us.”

Under the CD-CP, clinicians from the Child Study Center respond with police to emergencies that involve children who are victims or witnesses to violence or disaster. Clinicians can help police discern signs of trauma that might not be obvious. “The blank stare of a child doesn’t mean that they are OK,” says Marans, “but that they are very much not OK.” When police recognize that children need help, they may use breathing exercises and other therapeutic techniques to alleviate anxiety.

Two-person teams of police officers and clinicians follow up with visits to children and their families at their homes in the days following traumatic events. The teams look for symptoms of traumatic stress, and then invite the children and families to the program’s clinic for an intervention. The Child and Family Traumatic Stress Intervention (CFTSI), developed at the Child Study Center, increases communication and family support with the aim of decreasing the effects of post-traumatic stress in the peri-traumatic phases, within 30-45 days of a traumatic event or abuse.

A 2009 study at Yale found that children who participated in CFTSI were 65 percent less likely to experience symptoms of full PTSD after three months compared to children who did not undergo the intervention. CFTSI training is offered to other agencies beyond Yale that aim to help children affected by violence, and is now used by clinicians around the country.

In the past 25 years, the program has extended its reach to other communities not only around the nation but around the world. Through a partnership with the International Association of Chiefs of Police, CD-CP provides law enforcement officers with materials and resources to promote the best practices and methods that the program has developed through their long experience in New Haven. The CD-CP also offers a round-the-clock consultation service in which clinicians provide guidance over the phone to police officers at the scenes of emergencies.

For police officers and clinicians, learning to walk in each other’s shoes has been invaluable, most of all to the families that they are now able to help. “When one gets to learn firsthand about the experience of others,” Marans says, “It changes the way you look at the world.”

Community partners exemplify the notion that what is necessary to fix a community is already present within it. James Comer looks to the present shortage of primary care physicians in the United States as an example. “We are going to have a huge shortage of doctors because people say they can’t import them,” he says. “Well, what do you mean, you can’t import them? They’re here, they’re walking the street, they’re in your schools right now. You just mishandle the way you develop them.”

“They did a good thing harvesting us from the community,” says Stacy Downer. “I’m going to be passionate. This is my community. I love New Haven like I love my kids. I grew up here, and I intend for my kids to grow up here. Of course I am going to advocate for this agency that I feel I can trust, so I put my best foot forward.”

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