During an opioid overdose, the brain betrays the body. A single event—be it a rush of heroin or fentanyl or a semisynthetic prescription painkiller like oxycodone—sets off a series of repercussions: The drug travels from the bloodstream to the brain; it latches itself to opioid receptors; it suppresses the brain’s ability to control breathing rate; it blurs the brain’s recognition of dangerous carbon dioxide levels in the bloodstream; it causes the brain to cross wires in its communication with the diaphragm; and, finally, the drug causes failure in the lungs to breathe in and out as normal. The drug suffocates its user, systemically.
The suffocating tendrils of addiction reach wide.
In Martinsburg, West Virginia, addiction reached into the recesses of everyday life, winding around everyone and everything. Tiffany Hendershot—in her time as a social worker—remembers hearing sirens outside as she led a skills group of second- and third-graders. “Someone OD’d,” they said, in unison. Each of them could name someone they knew who had met the same fate. This was part of life in Martinsburg and across West Virginia, where approximately one in 2,000 people died of an overdose in 2016, according to the CDC.
Hendershot—now the project director of The Martinsburg Initiative, a communitywide effort to counter the opioid epidemic—carries with her these reminders of addiction’s reach and its impact on young people. This is the city where Spring Mills High School star football player Jorge Armando Mercado-Medrano overdosed in the summer of 2016. It’s where a first-grader dialed 911, alone in the house with a dead relative on the couch. It’s where a parent got caught using on the playground, his emptied McDonald’s bag of spoons and syringes spilling out on the sidewalk in front of the school.
Hendershot’s experience has shown her that the opioid epidemic is not just an issue of drug prevention. It’s an issue of proximity and of trauma, and it’s harming young people nationwide.
“Here’s what I see,” Hendershot says. “Kids coming through our doors exhausted from lack of sleep. Some sleeping in cars, tents, hotels or random couches. Kids not eating from lunch one day to breakfast the next. Kids getting themselves and their siblings ready for school each day. … Kids whose ACE [adverse childhood experiences] score is higher than the number of years they’ve walked this earth.”
The number of youth facing these adverse experiences due to living alongside opioid use continues to rise, sharply, as do death tolls and usage rates. Study after study finds that compounding ACE scores increase children’s risk for poor mental and physical health and for substance abuse later in life. In the meantime, their school work, sense of stability and behavior suffer.
According to experts, helping these kids will require two initiatives operating in tandem: a trauma-focused school environment and a coalition of community resources.
The Opioid Epidemic by the Numbers
To understand why the opioid epidemic is an education and child welfare issue, one must first understand its massive scale and reach. According to the latest CDC data, drug overdoses led to almost 64,000 deaths in 2016. Opioids were by far the leading cause of those overdoses, which show no sign of slowing. An analysis by STAT predicts that as many as 650,000 people could die from opioid overdoses in the next decade, more than doubling the over 300,000 lives lost to opioids and heroin since 2000.
And these are just the official numbers. Due to differences in local protocols, in funding and in the ways overdoses are reported, we’re likely underestimating the number of opioid overdose deaths by the thousands. With roughly half of opioid overdoses taking the lives of people between the ages of 25 and 44, children bear a huge burden. These are often their parents, their uncles and aunts, their guardians and mentors.
The numbers of deaths and displacements rise more quickly than the resources in place to quell them.
Richard Tench is a school counselor at St. Albans High School in West Virginia. He lives near Charleston, a five-hour drive around the mountains from Martinsburg, and he too has seen the way opioid use can spread to students’ everyday lives. For Tench, it’s become all too normal to see children orphaned or removed from their homes due to opioid-related death or negligence.
“We can’t keep up with the crisis at the moment,” he explains. “It’s not necessarily that [all] the students have chosen to partake in those drugs. It’s that the family’s been destroyed. … [T]he students are losing the structure, losing support and losing what they need.”
There is no magic bullet to fix what is happening to the children in our communities. This is a long-term strategy and we are in it for the long haul.
Not Just in Appalachia
This epidemic hit hardest in Appalachia, the Midwest and New England, as underscored by the five states with the highest overdose death rates per capita in 2016: West Virginia, Ohio, New Hampshire, Pennsylvania and Kentucky. But the opioid crisis is geographically quite diverse. According to an analysis by the Brookings Institute, more than three-fourths of counties in the United States saw one in 10,000 people overdose in 2015. Particularly affected communities included urban centers such as Baltimore, Denver and Philadelphia. From the southern tip of New Mexico to the eastern bays of Maine, the opioid epidemic is ravaging communities of all types and sizes—including communities of color.
The erasure of people of color in the coverage of the opioid crisis echoes a painful chapter in American history when the crack epidemic led to racist policies, prevention tactics and rhetoric. As Cardozo Law professor Ekow Yankah put it, “When the faces of addiction had dark skin, the police didn’t see sons and daughters, sisters and brothers. They saw brothas, young thugs to be locked up, not people with a purpose in life.”
But the coverage of the opioid crisis belies reality. The faces of this crisis do include faces of color. Overdose deaths among black Americans have skyrocketed since 2011 with the increased prevalence of synthetic opioids. According to Frontline, overdose death rates have also more than doubled among Latinos and Native Americans. This includes regions of the United States often left out of the conversation, as well as overlooked people of color in the heart of the epidemic. In Missouri, Minnesota, Wisconsin, West Virginia and Illinois, for example, black Americans are overdosing at higher rates than the general population.
Across all populations, the impact of an addiction epidemic trickles down. And students suffer on multiple fronts.
How the Opioid Epidemic Affects Children
A report sponsored by the National Institute on Drug Abuse found that 168,000 kids aged 12-17 were addicted to prescription painkillers in 2014; 28,000 of those tweens and teens had used heroin in the past year. The names of too many of these young people went from yearbooks to tragic headlines to tombstones. This is the most obvious—and perhaps most pressing—need revealed by the opioid epidemic. We are losing children directly to the cycle of addiction.
But by 2017, that same survey found heroin and prescription opioid use at historically low levels among middle- and high-schoolers—all while rates of adult opioid use continue to rise. Yet schools in heavily impacted areas are being called upon to serve as ground zero for the epidemic, their foundation of learning fissured by the addiction students witness daily.
Psychologist Anthony Mannarino, who directs the Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital in Pittsburgh, says he’s seen a dramatic increase in the number of kids whose parents have overdosed or lost custody of their children in the last few years.
“These kids can experience post-traumatic stress disorder; they can experience traumatic grief,” Mannarino says.
And for children who are still living alongside addiction? “For those kids, it’s not only a historical trauma that’s problematic,” Mannarino explains. “But it’s also the fear and anxiety associated with the possibility that something bad could happen today or tomorrow or next week.”
How Opioid Addiction Manifests in the Classroom
Like an opioid, trauma suppresses the brain functions that could save its victims. It enlarges the amygdala—the brain’s emotion factory—increasing fear and anxiety. The nucleus accumbens—built to reward and reinforce what is good—fails to function at full power. Activity slows in the prefrontal cortex, diminishing impulse control. The limbic system takes over. It’s fight, flight or freeze.
Trauma wears a mask that can look much like defiance; it can look like withdrawal, like anxiety or like a child has checked out. It therefore imposes itself onto classroom capability and behavior. Mannarino says children experiencing PTSD or ongoing anxiety often face “intrusive thoughts” while at school, making it difficult to concentrate, or they display behavior that may be misdiagnosed as signs of attention-deficit or other disorders.
“Since they’ve been exposed to situations that they feel are unsafe, it can result in these kids basically being hyper-aroused because of a lack of safety,” Mannarino says. “They’re fidgety. They can’t sit still. They can’t sleep.”
Drug prevention programs designed to merely shame drug use do not stop these behaviors. They internalize shame in children already suffering. Tiffany Hendershot’s work in Martinsburg approaches the problem differently.
“When we start looking at kids through a trauma lens, their behavior makes sense,” Hendershot says. “We step back and realize what they need most: relationship and safety. Once they have those two things, we can calm the limbic system to a regulatory state and help build connections to the prefrontal cortex so learning can happen.
“Bad things are going to happen. The Martinsburg Initiative can’t stop that. What we can do is build a trauma-informed community around kids and connect them to services to build their resilience.”
It Takes a Village: How to Best Support Students Affected by Opioid Use
To accomplish those goals, The Martinsburg Initiative focuses its work on what we know about ACEs. It begins with partnership: The schools, local law enforcement, nonprofits and health professionals have formed a coalition that purports to put community-building before crisis intervention. This coalition aims to provide greater access to resources and a humane, trauma-focused approach to prevention and treatment for those affected.
For her part, Hendershot is hell-bent on removing opportunity and resource gaps. She provides one-on-one consultations with teachers, informing a more trauma-focused approach to classroom and behavior management. Meanwhile, The Martinsburg Initiative is offering mentors and afterschool programs to students and families in need. They bring mental health providers into the schools, funded through Project Aware. And they are holding themselves accountable, promising wraparound support for students that will include home visits, therapist consultations and monitored progress.
It sounds ideal, if hard to replicate. The Martinsburg Initiative is funded, in part, by a $135,000 federal grant, and it benefits from local resources and law enforcement willing to endorse a trauma-focused approach. But the opioid problem is massive, so the solutions have to be even more so.
But What if We Can’t?
Even Tench, an exemplary counselor doing trauma-focused work, admits that some communities cannot replicate these best practices.
“I know that in more rural counties in my state that there are going to be a whole lot less resources,” he says. “With the increasing rate [of drug use], it’s also going to take increasing manpower to help out with the crisis.”
Not all school communities have the luxury of trained, willing, local practitioners or nearby cities where such practitioners might be working. According to the Brookings Institute analysis, more than 80 percent of rural counties with high rates of overdose deaths do not have a registered nonprofit that provides services for those affected by substance abuse. The same is true in more than half of suburban and small metro counties. Lack of access has led those seeking help to drive hours to the nearest treatment facility. For schools in those communities, help feels far away, and a partnership like Martinsburg’s feels impossible.
But these school districts can make small changes to better support students affected by the opioid crisis. If it’s legal in their state, schools can make sure school nurses or trained personnel have Naloxone—an opioid antidote administered to people experiencing an overdose. Home visits, according to experts, can help reduce child abuse and neglect that may arise due to opioid abuse. Instilling these interventions into the school culture also helps foster relationships between educators, students and families. Further, districts can require counselors to learn trauma-focused techniques and make sure policies surrounding discipline and truancy are edited through a trauma lens.
In Pittsburgh, Mannarino helped create and continues to use Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to help children process and bounce back from trauma.
That recovery begins with an understanding of what the children are going through. School leaders can build this understanding into discipline policy, and school counselors and psychologists can build it into practice.
The TF-CBT approach builds coping skills, so children can better deal with thoughts and feelings triggered by their trauma experiences. One example of this is the focus on helping children get past feelings of guilt. Mannarino says many patients who have witnessed overdoses—some as young as 6 years old—carry with them these distortions: “It’s my fault.” “I should have saved her.”
“We know that kids who have experienced trauma… that their brains have changed, that they have an overactive alarm system in their brain,” Mannarino explains. “We encourage kids to talk about what happened, to process their memories, not to be avoidant, not to be scared of their memories.”
In a perfect world, Mannarino says, schools could help combat this by partnering with mental health professionals who could train teachers and guidance counselors in trauma-focused care.
Schools can also integrate evidence-backed programming—such as Seeking Safety, developed by Dr. Lisa Najavits—into their counseling, intervention and afterschool services. Without partnerships, programs or better policies, teachers are left in a too-familiar position: tasked with providing the first and last line of support for students experiencing trauma.
Hope for an Antidote
Hope can feel like a scarce resource. In Martinsburg, alone—population: roughly 18,000—nearly 200 overdoses occurred in 2016. And 18 people died. There’s no getting those lives back. But Hendershot and others believe that, going forward, they can counter the crisis.
“There is no magic bullet to fix what is happening to the children in our communities,” Hendershot says. “This is a long-term strategy and we are in it for the long haul.”
Experts in trauma-focused care say Hendershot has some reason to keep going. They say that this work with the younger generation can reduce the risk that these children repeat the cycles of addiction, neglect and abuse.
It’s reason enough for classroom teachers to view students through a trauma lens, and for school leaders to make sure they promote a trauma-focused environment. Even small steps help.
“These kids do well. They get better,” Mannarino says. “[With trauma treatment,] they have good outcomes. PTSD, depression and anxiety disorders significantly decrease in magnitude.”
And just like that, for some, so much that has been suppressed by trauma resurfaces. Attention. Control. Self-worth. Calm breaths come easier to combat those old, suffocating thoughts.
When Naloxone enters the body, it aims to counter the opioids’ suppression of the brain. The antidote lies in wait, ready for the moments when opioid molecules fall from the receptors they attacked. Then the Naloxone grabs on before the opioid can once again take hold. When successful, breathing is restored, brain and body in concert once more.
The antidote works by restoring what the drug has taken away.
Collins is the senior writer for Teaching Tolerance.
What Educators Can Do Right Now, No Matter the Resources
Sometimes, it’s the little things.
Hendershot recalls a boy who was often late to school and often referred to her due to bad behavior. She got to know him, and understood why: Due to substance abuse, his guardian wasn’t always present in the mornings. He didn’t have a clock. He didn’t have a way of knowing when to wake up. And he didn’t have help.
So, Hendershot and others got him an alarm clock. He learned how to set it. He learned what time the bus stopped at his house. And he started getting himself and his brother to school on time to eat breakfast. This small gesture—a single clock—offered him a sense of resilience, and an empathetic message: We don’t want to keep kicking you out of class; we want you here. A lesson in the power of knowing your students.
“It starts with building those relationships. Building that level of trust and rapport is how we find out that the students are going through things,” Tench says. He adds that teachers are in a unique position to have insight into a student’s changing behavior and should act on it in a positive way.
Teachers can also put a trauma-focused pedagogy into practice. This may mean changing the way they react to defiant behavior and making sure discipline takes the child’s past and present into account.
“The traditional ways to change behavior do not work with children who have experienced trauma,” Hendershot explains. “When you tell a student they have to ‘clip down’ on the behavior chart, most will think, ‘I did something bad and need to do better to clip back up.’ A child experiencing trauma has a negative view of self and will think ‘I am bad and this confirms it.’”
Instead, she recommends teachers learn the Nurtured Heart Approach to discipline, or implement The Zones of Regulation to help students with impulse control. Strategies like these can help students gain a more positive sense of self and independence in understanding their own emotions and behavior.
Implementing a trauma-focused pedagogy may also mean integrating aspects of mindfulness into the classroom. Dr. Mannarino says that one of the important facets of TF-CBT is teaching kids relaxation and coping strategies “so that they can calm their body down, calm their mind down.”
Educators who are trained and equipped to deal with the sometimes unexpected responses that can result from meditation can help students experiencing trauma learn mindfulness techniques to find calm and solace from intrusive thoughts. Educators who do not feel equipped can still lead their class in basic breathing exercises and learn what helps to calm a student facing trauma, such as quiet time, writing or a personal comfort item.
Lastly, teachers can help shift the conversation surrounding drug use.
It’s a need author Mindy McGinnis saw when she visited a school district hit hard by the opioid epidemic. A place, according to her hosts, with three primary employment opportunities: the school, the hospital or selling drugs.
“I could imagine these teens seeing the adults around them trapped, geographically and mentally, in this world,” she said. “And how it could suck the life out of their hopes for their own future.”
This inspired McGinnis to write Heroine, a book about addiction and its impact on youth set to be released in 2019 by Katherine Tegen Books. She believes teachers, too, can help change the narrative. In towns hit hardest by opioid use, the topic will come up in class. McGinnis sees it as an opportunity—not something to shush and shame.
“More open conversation about addiction is necessary,” she said. “Not in the basic sense of ‘drugs are bad,’ but rather, ‘people make mistakes and mistakes can be rectified.’”
This means acknowledging, she says, that addiction is not a “them” problem, but an “us” problem. An issue, like most, that derives from systemic failures, not just personal choices.
For children experiencing trauma, removing this boundary of shame may help them start on the path toward healing, building the ability to reflect without self-judgment or guilt, but with self-worth, instead—and perhaps with a feeling like hope.
This toolkit and additional resources can help educators respond to student behaviors in trauma-sensitive ways.