Building Hope from Tragedy: Trauma-Informed Healthcare in St. Louis Schools
Additional Reporting by Eric Berger
Is it possible to sound a note of hope and optimism in the midst of a summer that saw 13 children killed by gunfire in St. Louis? Can we do it when six of those homicides occurred as our community was marking the fifth anniversary of the police shooting of 18-year-old Michael Brown, Jr.? When three happened in a single weekend, August 23–25?
As tragic and needless as it was, Michael Brown’s death on August 9, 2014, provided an opportunity for redemption. It fueled a national conversation around equity, racial disparities, and policing. It kindled a protest movement and new community leaders, some of whom remain prominent voices today. It spawned the Ferguson Commission, which issued 189 calls to action to address racial inequities in our region. And that led to the creation of this organization, Forward Through Ferguson, a nonprofit aimed at catalyzing the community and turning those calls to action into actual action.
And yet, five years later, our youth seem less safe.
Particularly poignant were the words from Dawn Usanga, whose child Xavier, an innocent bystander, was shot to death when two armed men got in a dispute on the afternoon of August 12, 2019, in the 3500 block of North 14th Street.
“In a way, I’m happy he died at 7,” Ms. Usanga told the St. Louis Post-Dispatch. “The streets didn’t have a chance to ruin him. He could have just as easily been swept up in this war, and the boy who shot him could have been my boy someday.”
Ms. Usanga’s pain should weigh heavily upon our entire region. And yet, even at this incredibly bleak time, we can find reasons for hope.
Over the last five years, many St. Louisans have stepped up forthrightly, sensibly, and scientifically to address the root causes of violence and despair. They have gone beyond applying band-aid measures and instead are implementing sustainable systemic changes that are beginning to make a difference even as the headlines suggest the problem has grown worse.
Many involved in the work have already demonstrated proof of concept. What remains is bringing these projects up to scale, so every child can benefit.
This is how Nancy Cambria looks at the world, and she has seen it from three perspectives since she arrived in St. Louis just over 20 years ago.
As the children and families reporter for the St. Louis Post-Dispatch, Cambria wrote a series of stories describing the impact of toxic stress on people of color. Included in her work was research from “For the Sake of All,” a report jointly produced by faculty from Washington University and Saint Louis University and published just months before the killing of Michael Brown, Jr. The report described health, education, and neighborhood disparities between white people and black people in the St. Louis metropolitan area. Most breathtaking in that research was the finding that a child growing up in 63106 (north St. Louis City) has an expected lifespan that is 18 years shorter than a child who grows up in 63105, which encompasses the municipality of Clayton. Clayton is the county seat and a nearly all-white community, where the median home price is well north of $500,000.
Cambria said a variety of factors contribute to that dismaying statistic, but trauma and toxic stress play a big part because they wear down the body in distinct biological and neurological ways that have been extensively researched.
In 2017, Cambria went on to work as communications manager for For the Sake of All, which has since been rebranded as Health Equity Works. She now is director of community relations, media, and development for the University City School District.
Cambria collaborated with educators, academics, physicians, social workers, and children to first describe the issue of toxic stress in the Post-Dispatch. In her subsequent positions, she helped build systems to support African-American children and families who have disproportionately experienced trauma and toxic stress. In those roles, she began to particularly communicate the role of schools and how they could help or hinder children dealing with trauma.
A lot of the work involves helping schools to build systems that take into account the federal Whole School, Whole Community, Whole Child model created by the Centers for Disease Control and Prevention. The model describes many factors that should be present in schools regarding health and well-being to ultimately help student learning. At U City, Cambria said, the schools strive for cultures to ensure children — and adults — are loved, challenged, safe, included, cared-for, heard, and empowered to make positive change.
The reason for doing so was perhaps best described by Dr. Jason Purnell, associate professor at Washington University and principal investigator and project director of Health Equity Works:
A child who can’t see, can’t hear, can’t breathe, hasn’t slept, has been traumatized, or doesn’t know where they are going back home to at night simply does not have the opportunity to learn, unless we help them — none of us would. So before we get to reading, writing, and arithmetic, we have to get to these basic needs of so many of our children.
Cambria says St. Louis is “getting ahead of the curve” and is on the way to becoming a national leader in bringing trauma-informed care to students. It’s happening at schools across the region, including in the Normandy, University City, Jennings, St. Louis and Rockwood districts, as well as at charter schools, such as Lift for Life Academy and the Confluence charter system. And it is bringing together a variety of stakeholders — businesses, school districts, universities, hospital systems, federally qualified health centers — that, while well-intentioned and effective in their realms, were siloed and falling short in addressing the everyday needs of families and children.
A Missouri Model
The St. Louis area began to get ahead of the curve with the work of an organization called Alive and Well Communities, a nonprofit that operates statewide.
Alive and Well hosted forums and get-togethers with educators and clinicians to arrive at a shared set of facts.
Jennifer Brinkmann, the nonprofit’s president, credits the Missouri Department of Mental Health for providing a framework for trauma-informed care, referred to as “the Missouri Model.” “We launched a pilot learning collaborative in 2016 with more than 20 different school buildings across the region, to talk about how to implement the Missouri Model for trauma-informed care in schools,” Brinkmann said.
“We asked, ‘How do we work with schools to apply this model?’”
Alive and Well then began working with a pilot group of schools “to test how to help support schools in that transformation to become trauma informed. Through that process, we saw some change in a lot of buildings and learned a lot. And we were able to identify a core group of educators that were real advocates for child well-being, and who wanted to be leaders in advancing this work.”
University City Public Schools Superintendent Sharonica Hardin-Bartley was among the leaders who embraced the concept. Hardin-Bartley chairs an education leaders’ working group organized around child well-being, with trauma-informed care as a core component.
Districts across the area have tried different approaches, with the establishment of school-based health centers appearing to offer particularly great promise. The opening of more centers sparked interest in creating a local affiliate of the National School-Based Health Alliance. A grant from Express Scripts of $350,000 to Health Equity Works furnished the statewide expansion of the Missouri affiliate, the Show-Me School-Based Health Alliance.
The Rubik’s Healthcare Cube
A school-based center can offer a variety of health services that disadvantaged families frequently have trouble accessing. These can range from vaccinations to physicals to care for such maladies as diabetes, skin rashes, asthma, and mental health issues.
But in the early stages no one has found a quick and easy way to start a center. The work is painstaking and incremental. Health Equity Works helped to facilitate these efforts through a workgroup featuring leaders in healthcare, education, and business so they could partner with resources and collaborate to create such centers. Their work also spun off the aforementioned Show-Me School-Based Health Alliance. But still, the work is complex.
“The main thing that you hear is, ‘If you’ve seen one school-based health center, you’ve seen one school-based health center,’” said Dr. Douglas Perry, assistant vice president of community health services at Affinia Healthcare, a nonprofit agency that provides primary medical services.
As part of his duties, Perry has played a role in establishing school-based health centers at Normandy High School, Lift for Life Academy (a charter in South St. Louis City), and Aspire Academy (a charter in North St. Louis City).
Perry, in concert with teachers, principals, physicians, nurses, school counselors, and social workers, was challenged to solve the healthcare version of a Rubik’s cube. The center’s services must be at once accessible, affordable, and efficient. And someone has to pay the bill, whether it’s taxpayers, foundations, or civic-minded businesses. Affinia’s role is important, because it is a federally qualified health center and can attract a higher Medicaid reimbursement rate.
Every site is different, Perry said, “from the floor plan and the layout, to the services delivered, to how the function between the district and the health system work and their funding. Each location and each partnership need to come to an understanding of how it’ll work and what’s the best way to make it happen.”
But when that last cube in the Rubik slides into place, it’s gratifying to all involved — perhaps particularly so to Dr. Karen Paschel, the nurse practitioner at Normandy High School. She sees a younger version of herself in the students who visit the clinic.
Paschel, who has a doctorate in nursing, was raised by an aunt in north St. Louis and saw how her peers struggled to stay focused on their education while dealing with health issues or family dysfunction.
“Every kid that comes in here, I ask them, ‘What are your plans for when you leave here? Because eventually you’re going to leave here, and we want to make sure that you’re successful,’” Paschel said.
Affinia staff stay in close touch with Normandy High principal Pablo Flinn, who moved over to Normandy in 2017 from the Ladue School District, where he served as an associate principal and as director of education for student support and assessment.
“Having [the health center] on campus allows the space to feel like a community space. This is where we are going to support your whole child,” Flinn said. “We want them to grow academically. We want them to be healthy physically, socially, and emotionally, so it’s a natural extension of what we should be doing.”
The center is located in a building that also houses the maintenance and transportation offices. It features a waiting room and two exam rooms; students from preschool through twelfth grade, parents, and community members can receive treatment there. The center is open two and a half days each week — plus some additional hours where a social worker is available — but Flinn hopes to expand those hours. (A nurse is still employed full time at the school.)
“Ideally, anyone in the region who needs a service could access a service,” Flinn said.
Some of the most significant benefits for students have been giving them the opportunity to receive a yearly physical on campus and providing them access to a licensed social worker, Flinn added.
Students who would otherwise need to wait for a parent to drive them to a doctor to have a physical can now take care of it on campus. Flinn explained, “When a family is moving in, and there are vaccinations that are missing, we’re not saying, ‘Go get it done; go figure it out on your own.’ Instead it’s, ‘What can we do?’”
Kiera Murray, 17, a senior in Normandy’s Center for Academics and Social Advancement (CASA), an alternative high school, has visited the health center often for a variety of health services. Instead of having to leave the campus, perhaps missing class, and having to return with a doctor’s note, Kiera can just walk over to the clinic. It also spares her mom, Debra Wilson, from having to take time off from her job.
“It’s very convenient,” Wilson said. “The only thing I wish is that it would be open every day of the week. Something can happen any day.”
Kiera says she has forged a strong bond with one of the clinic’s social workers, whom she calls Miss Kate.
“She has been a mentor for me. She would [help me] with anger management and give me some coping skills. I liked her. She was real.”
Eliminating Barriers
David Campbell, a physician, had been working on student health issues long before #Ferguson. In recent years, his efforts have drawn even more support and respect.
Campbell is president and chief executive officer of IFM Community Medicine, an organization that provides health services for youths and families in a variety of settings. IFM Community Medicine partners with such organizations as Crisis Nursery, Epworth Children’s Home, and Youth in Need. Campbell also serves as medical director for a dozen area school districts, including the St. Louis Public Schools and the Special School District.
“We partner with schools or shelters or other social service organizations to bring care to their clients or their students by taking it directly into their walls,” Campbell said, “so we set up small clinics within the walls of these other organizations to take care of the individuals that they’re providing other services for. We eliminate the barriers to accessing healthcare by taking the services directly to them, and by partnering with the agency.”
In doing so, Campbell said, “We eliminate one of the big silent barriers to healthcare, which is distrust of the traditional system — sort of the ‘intimidation factor’ for many folks.”
Beyond Clinical Care
Having healthcare professionals on site is very important, but trauma-informed care can also be administered in classrooms, on field trips, and in the public sphere.
“We work on things that build resilience in children,” said Nancy Cambria of University City Public Schools. “We work with a social justice mindset to show our students that they can do projects to make change in the world. Enabling students who have experienced trauma to help their peers and others is empowering and will help them succeed in school and life.”
The school district introduces the concept of public service projects in grade school and continues them in ever more sophisticated ways all the way through high school.
Recently, a group of students conducted a march for clean water. Others started a community garden with the produce donated to immigrant communities. Students have demonstrated against school gun violence and they raised money two years ago to help nearby Loop businesses damaged by vandalism after a judge found former city police officer Jason Stockley not guilty in the shooting death of Anthony Lamar Smith.
“We provide wrap-around services with our partner Wyman. We also practice restorative justice,” Cambria said. “When a wrong is committed, our students and teachers, and sometimes parents, sit in a circle to discuss the issue and talk about the best way to make amends. We call it discipline with dignity.”
This spring, University City students, along with those from St. Louis Public Schools, Ritenour, Hazelwood, and Parkway, participated in a Youth Ambassador Academy sponsored by Alive and Well. The assignment: Draft a plan to relieve stress at school.
The suggestions were concrete and practical. For instance, create a buddy system in which seniors take freshmen under their wings. Establish a quiet room where students can go when they feel overwhelmed. Students also learned how to advocate for changes they want to see by setting up meetings with administrators and bringing credible information and testimony to the table.
Cambria says the district has also invested resources and time in training staff to build relationships with students that go beyond lesson planning. “I’m particularly excited about the power of relationships,” Cambria said. “Remember the teachers who had the most positive impact on you? Well, they intentionally built a strong relationship with you.
“We aim to address students where they are and how they are feeling about their world. That isn’t to say we should feel sorry for them because of their hardship and then give them a pass. Rather every child should feel included, and challenged to perform academically and to make a better world for themselves and their communities.”
