Angela Delyani, community health worker; Mariah Cahill, crisis services advocate; and Sgt. Matthew Larochelle knock on the door of a family with children who witnessed a domestic violence incident just days before.
An often-overlooked aspect of the opioid epidemic that has exploded across the U.S. in recent years is how often the abuse of heroin or prescription opiates is accompanied by domestic violence. This is tragic enough for the adults involved, but it’s a ticking time bomb for children who are exposed to these adversities, raising their risk for future drug use and multiple health and mental health conditions. Here’s how one community is trying to address the problem.
Police officers and emergency dispatchers are a pretty tough bunch but about three years ago, 911 operators in Manchester, NH, began noticing an uptick of an exceptionally distressing call—from children reporting the overdose of their parents.
“These little kids were finding their parents passed out or dead in their apartments, and they were the ones calling 911,” said Sergeant Peter Marr, who supervises the Manchester Police Department’s sexual and domestic violence unit.
Few places have been hit harder by the opioid epidemic than New Hampshire and its largest city, Manchester. In 2014, the city of 110,000 people had 48 fatal overdoses. In 2015, the number spiked to 106. That year, New Hampshire had the second-highest rate of deaths from overdose of any state in the country.
Many of these same children were also exposed to domestic violence — more than 400 kids had that experience in 2014, according to police department numbers. Yet unlike adult victims of crime or domestic violence, who often have access to counselors or advocates, no such services were routinely available to children.
“We realized these kids are right there, they’re witnessing all these traumatic events and are being affected,” Marr said. “We offer all these services to victims but almost none to the kids.”
In early 2015 Manchester’s new police chief, Nick Willard, asked senior members of his department to explore what could be done. So Sergeant Paul Thompson reached out to Lara Quiroga, program director of Project LAUNCH, an early intervention program for children and families that is part of a national effort funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
Thompson’s message was simple, Quiroga recalls: “Kids are seeing parents being abused or going to jail. They’re calling 911 because their parents are incapacitated or dead. The chief wants us to figure out how we can help. We’re not social service providers, we’re a paramilitary organization. How can we get kids connected?”
Quiroga and Jessica Sugrue, the CEO of the New Hampshire YWCA, began meeting with police representatives to explore what could be done. At their first meeting, they talked about the Adverse Childhood Experiences Study (ACE Study), the groundbreaking project led by researchers from Kaiser Permanente and the Centers for Disease Control and Prevention. The study has shown that people exposed to trauma and other adverse experiences as children face a dramatically increased, lifelong risk of health and mental health problems.
The ACE Study looked at how 10 types of childhood trauma affect long-term health. They include: physical, emotional and sexual abuse; physical and emotional neglect; living with a family member who’s addicted to alcohol or other substances, or who’s depressed or has other mental illnesses; experiencing parental divorce or separation; having a family member who’s incarcerated, and witnessing a mother being abused. Subsequent ACE surveys include racism, witnessing violence outside the home, bullying, losing a parent to deportation, living in an unsafe neighborhood, and involvement with the foster care system. Other types of childhood adversity can also include being homeless, living in a war zone, being an immigrant, moving many times, witnessing a sibling being abused, witnessing a father or other caregiver or extended family member being abused, involvement with the criminal justice system, attending a school that enforces a zero-tolerance discipline policy, etc.
The ACE Study is one of five parts of ACEs science, which also includes how toxic stress from ACEs damage children’s developing brains; how toxic stress from ACEs affects health; and how it can affect our genes and be passed from one generation to another (epigenetics); and resilience research, which shows the brain is plastic and the body wants to heal. Resilience research focuses on what happens when individuals, organizations and systems integrate trauma-informed and resilience-building practices, for example in education and in the family court system.
The ACE Study found that the higher someone’s ACE score – the more types of childhood adversity a person experienced – the higher their risk of chronic disease, mental illness, violence, being a victim of violence and a bunch of other consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information, go to ACEs Science 101. To calculate your ACE and resilience scores, go to: Got Your ACE Score?)
High ACE scores also relate to addiction: Compared with people who have zero ACEs, people with ACE scores are two to four times more likely to use alcohol or other drugs and to start using drugs at an earlier age. People with an ACE score of 5 or higher are seven to 10 times more likely to use illegal drugs, to report addiction and to inject illegal drugs.
The Manchester team’s first move was to create a position through the Americorps program for a victims’ advocate who could provide support to adults or children exposed to domestic violence. They also convened a larger group of service providers to figure out next steps, and how to address a key problem: As officers and the victims’ advocate came into contact with children experiencing trauma, how could they get help for those children without violating the privacy rights of their parents?
“We didn’t just want to have the police officer or child advocate tell parents, ‘You should call this agency,’ but then never really know if they called,” Quiroga said.
The police department changed its protocol so that when officers follow up on a 911 call about domestic violence or other potentially traumatic event, they will routinely determine whether a child was present during the event. If the answer is yes, the officer is supposed to tell the parents how difficult such events can be for kids and suggest that they sign a form authorizing a child advocate to call them.
The officers can then give the family’s name to an agency so a staff member can contact them and arrange a visit. To protect the family, the form doesn’t authorize the agency to provide any information to the police.
In the nine months after the city began using the form in October 2015, 37 families signed it, enabling their 51 children to be referred for services. But that, Quiroga said, was just a small first step.
She and members of the police department continued meeting and learned about the Child Development-Community Policing program in New Haven, CT, where cops and mental health professionals work together and receive training in child development and policing strategies.
Inspired, the Manchester police and Project LAUNCH sought and obtained a three-year, $150,000 grant from the HNH Foundation, a New Hampshire grant-maker focused on community health issues. They brainstormed a name and came up with ACERT, the Adverse Childhood Experiences Response Team.
Quiroga and Sugrue from the YWCA led training sessions about adverse childhood experiences for 34 officers and more than a dozen advocates and community health workers. The training reviewed the vast body of science that has emerged in recent years from the ACE Study on the powerful role that adversity and trauma have on the developing brains of children, and on their physical and emotional wellbeing.
For the police officers and first responders involved, the training also included “reflection about their own trauma history and how it can impact their behavior in situations they respond to,” Quiroga said.
In July 2016, a joint-response team comprising a police officer, a mental health professional, and a community health worker began visiting the homes of families where a violent or traumatic incident involving children had been reported to police.
The HNH grant provides only enough funding for the team to operate four hours a day twice a week, on Wednesdays and Thursdays from 5 pm to 9 pm. During those times, the team responds directly to any calls that come in, “going in immediately after the first responders say it’s safe,” Quiroga said.
Team members try to speak with the parents and the child, figure out an appropriate referral, and get the release form signed. When they’re not in the field on immediate calls, the team follows up on calls from the previous week and visits families who have signed a release.
Responding in the days following an event, rather than in its immediate aftermath, is sometimes better for the family, said Marr, who, like other team members, rotates on and off the response team. He recalled the time his team went to a family’s home because of a loud argument between a teenage girl and her immigrant parents. No one was in physical danger and the parents, embarrassed at having police officers at their home, wanted them to leave as quickly as possible.
“We were trying to discuss ACEs with them and they wanted us out,” Marr recalled.
The team went back later for a follow-up visit and this time, the parents were more receptive. They agreed to a referral to get help for their daughter.
As the ACERT team began making home visits, the number of families agreeing to refer their children for help began rising. Through the middle of June 2017, the team has reached out to 228 families and 164 of them signed referral forms, allowing their children to get services.
Some children are seen by therapists at Project LAUNCH, which recently hired a psychologist, Cassie Yackley, to train them in a technique known as child-parent psychotherapy that is used with parents and their young children. Yackley is also training first responders – firefighters and cops — to better understand trauma and its effects on people.
A local art therapy program called C.R.E.A.T.E! (Center for Expressive Arts, Therapy and Education) that operates out of a former candy factory and looks like a castle, is also starting groups for children, Quiroga said.
For the police officers on the team, it can be frustrating not knowing whether a family and child makes use of the services; in many cases, they only learn more if more violence occurs and they are dispatched to the family’s home. But that, said Marr, is the nature of police work.
“Sometimes it’s hard to get through to people; they think if they sign they are admitting they’re bad parents or that their kids are messed up,” Marr said. “That’s one of the big hurdles we have to get through.”
The team has had better luck convincing another group that initially was somewhat skeptical, Marr said: his fellow cops.
“For officers, it means more paperwork, more stuff to do on top of an already difficult job,” Marr said. But the program has given officers another way to respond to the deepening crisis so many families are experiencing — and has convinced many of his colleagues that it’s worth trying.
“We can all think of multiple calls where you’re walking out and thinking, ‘Those kids don’t stand a chance,’ Marr said. “This is our chance to reach those kids who are on the bubble of possibly going down the same road. This is our chance to make a difference for those kids.”