Early evidence trickling in at Le Bonheur Children’s Hospital forms the outer boundaries of just how different life is in many Memphis homes now, including a 250% increase in self-reported depression or mental illness among adults and a 350% increase in violence in their homes and neighborhoods.
What that constant stress means for children, including how it affects brain and social development, is well documented in extensive research of adverse childhood experiences.
ACEs are traumatic experiences before age 18. They include all types of abuse, neglect and parental mental illness, but also substance use in the home, divorce, incarceration of a caregiver and domestic violence.
“As parents become more stressed, that places children living in the household at more risk for physical abuse and neglect,” says Dr. Jason Yaun, head of the outpatient pediatric division at Le Bonheur and medical director of the Family Resilience Initiative.
“The child may be more likely to act out and have behavioral or mental health issues, which in turn only increase the risk of things like abuse and neglect. It really ramps it up into a cycle.”
Having four or more ACE experiences predisposes a child to a range of chronic diseases later in life, including cancers, heart disease, strokes, COPD, diabetes and Alzheimer’s, plus a host of high-risk behaviors, including drug use.
Since the pandemic hit, a sample of the 500-plus families in the Family Resilience project have also reported a 35% increase in ACEs. What this means in the lives of these children and for the society they will live and work in is hard to fathom.
“We probably don’t know what this means,” said Chris Hanson, pediatrician at Laurelwood Pediatrics, “because we don’t know what’s out there that is not being reported.”
In 2018, Le Bonheur created the Family Resilience Initiative to help families with children — ages 5 months to 5 years — who have experienced three ACE events. About 95% of the participants are insured by TennCare.
By surrounding them with services including food, money for rent and utilities, access to hundreds of medical specialists in the Methodist Le Bonheur hospital system, and staying in touch, its leaders hope to reduce the severity of ACEs in Memphis, particularly now.
“If they have any adverse childhood experience, we offer them a referral to our psychologist,” Yaun said.
In May 2018, 15 families accepted psychological help. This May, the number nearly tripled to 44.
“I think the increase has to be what’s going on in our nation. I don’t think it’s anything we are doing, as wonderful as our outreach coordinators are,” Yaun said.
“It’s the stress and reality many of these families are facing.”
The project enrolls families who qualify when they come for well-child checkups at Le Bonheur’s out-patient pediatric clinic. The statistics were gathered from families enrolled in May and June.
Even in normal times, many of pediatrician Andrew Nearn’s patients at Christ Community Health Services live with unnaturally high levels of stress.
The pandemic has magnified it to a “tonic level of toxic stress” that puts them in a perpetual state of fight or flight, he said.
“The analogy is, you see a bear in the woods. Your adrenaline starts pumping. You have this fear that you are going to fight the bear or you are going to run,” Nearn said.
“Now, the bear is there 24 hours a day. A lot of folks have been sidelined by their jobs — laid off or let go altogether. The stress has just ramped up.”
This level of stress and fear, while a child’s brain development is “cranking along,” he said, physically changes the amygdala, the part of the brain where fear registers.
“With MRI, magnetic resonance imaging, you can see differences in a brain from a kid who has ACEs compared to someone who doesn’t,” Nearn says. “The fear part of the brain is changed. It is not normal. It is just not normal.”
In Shelby County, 12% of the population report experiencing four or more ACE events, which means it’s not unusual, Nearn says, for parents to be victims of neglect, abuse or the mental illness of their own parents.
“You talk about women who are rock solid,” Nearn says. “When you see their kids come in, you wonder, ‘How on earth are you taking care of these kids?’”
Families in distress
Tammy Ward has five children, including a set of twins born prematurely. At 4, one of them is nonverbal and clings tightly to her mother in the presence of strangers.
Ward also has two stepchildren living with her.
In April, her husband died of a heart attack after a seizure. She works full-time, Thursday through Monday, as a cashier at a convenience store on Summer Avenue.
“We are right now dealing with the fact that their dad has passed,” she said. “It’s hard. They ask about him.”
Last week, she enrolled in the resilience program. Among other things, she will now get a series of texts from the staff to make sure things are fine at home, including that there are groceries and money for utilities.
“If you say you are going to try to get groceries or something else in three days, we will call on the fourth or fifth day to see how it worked out,” said Cheryl Jackson, outreach counselor.
“We want to be proactive. We want to get to you before anything happens and be that extra leg or someone you can call rather than you sitting at home trying to figure out how am I going to get the things my family needs.
“You are still going to worry, but at least you can call someone.”
In the pandemic, Ward’s world has contracted to work, her children and the worry that she will bring coronavirus home from customers refusing to wear masks.
“This one right here gets sick with anything,” she said, nodding to Tiny, the smaller twin. “I have to keep myself healthy too. Once I leave there (work), I have to come home.
“I’m all they’ve got, and they’re all I’ve got. Everything revolves around my kids.”
Tiny is underweight for her age, walks with a limp because one leg is longer than the other. Until recently, Ward didn’t allow her to go outside because the sunlight seemed to hurt her eyes.
“Every time we pass one obstacle, we run into another thing,” she said. “But I keep a positive frame of mind. As long as I do, my kids have one too.”
She’s managing, she says, out of her own determination.
“In the face of what she is facing, strong is not a big enough word,” said Marissa Gray, one of three outreach counselors in the resilience program.
“She’s fierce. We want to keep these kiddos healthy, but in order to do that, there is a family unit,” Gray said. “The health of the whole family is really what we noticed determines the health of those children. That woman in there is just as much a key to her children’s health as the immunizations are.”
The resilience program is funded through grants. Extra money now is flowing in for utilities and rent support.
“Our donors have been very generous,” Jackson said.
Longer-term outlook
The situations that cause ACEs are often tied to how people have learned to manage stress or the frustration that boils over when there isn’t enough time, money or support. In Shelby County, the most common adverse experiences for children are being around substance abuse, emotional abuse or domestic violence.
Severity is determined by several factors, including how long and how intense the experience was.
“If it’s something like sexual abuse, that one time is likely to be adverse childhood experience,” Yaun said. “If it’s some type of physical neglect, it may be something that over time becomes an adverse childhood experience.”
In the pandemic, when schools were shut down and doctors’ offices were closed to in-person visits, the reporting network for child abuse nearly vanished.
The first positive case of coronavirus in Shelby County was reported on March 8. By the end of the month, calls to the Tennessee Child Abuse Hotline were down 19%.
“We are feeling the downstream effects and the collateral damage of not just COVID, but also the measures we’ve had to take in regards to isolation to keep everyone safe,” Yaun said.
“Some were unavoidable in some ways, but also there are things that could have been done certainly better with supporting families and children.”
Most people, he said, could predict the pandemic would cause more food insecurity and housing problems and, even six months into it, measurable levels of toxic stress.
“The fact that they are already turning into adverse childhood experiences, and at the rate that they are, was surprising and concerning to me.”
The vulnerability for children and families is immense, Gray says.
“Anytime you mix a pandemic and the fear of not getting clear information, with lack of resources — especially child care —you are adding a lot of stress to families, financially, emotionally and physically,” she said.
“But you’re also seeing a lot of resilience in families. That is what we are here to empower in any way we can.
“We’re seeing a lot of families really pull together, work with other generations, work with their communities and really being open to how they can adapt. I think that is what we are seeing the most.”
What stress looks like in children often depends on how old they are, experts say.
Jackson has noticed an uptick in complaints of children not being able to sleep, including babies waking up crying for no apparent reason.
“We call those night terrors,” she said.
There may be a general regression in toilet training or other benchmarks toddlers have achieved. In slightly older children, parents may notice grumpiness or sullenness and behavioral issues.
“By elementary school age, it may be physical symptoms - headaches and abdominal pain. We are definitely seeing more of it now,” Hanson said.
In the spring and early summer, Christ Community did pediatric visits on video platforms for behavioral and ADHD issues.
“We are able to kind of get a glimpse of what is going on in the home,” Nearn said, noting it was a view doctors haven’t had before.
“Now that city has been opening up, we are starting to see more of these kids come in the clinic. You can feel a level of tension that was not quite there before,” he said. “Like parents saying, 'I don’t know if I can afford this medicine. Can we wait?'”
In the absence of the hot school-lunch program, Nearn also says many children are eating less.
“Parents will say, ‘He’s just not eating a whole lot.' I think if you unpack that, it might be, ‘He’s not eating much because we don’t have a lot right now. The food pantry was not in my neighborhood today. We have to wait until tomorrow.’”
The positive thing, Nearn says, is that however long the pandemic lasts, it won’t be forever.
“At some point, people are going to recover. The catch though, is supporting people during the hard time. Times are really hard for lot of people right now.”
For that reason, Hanson says it’s particularly troubling that well-family checks the state Department of Education was ready to do have been sent back to the drawing board.
“I get the politics there a little bit, but it’s a shame we are going to let those politics keep at-risk kids from being checked on.”