[SLIDE 2. Nightclub memorial photo]
Many of you will remember news coverage of the horrific fire that engulfed the Station Nightclub, killing 100 people and injuring 190 others. Nearly 150 children had parents who died or were seriously injured. The widespread devastation among the residents of the small town of West Warwick, Rhode Island, is beyond the ability of words to convey.
A lifetime of professional experiences has made me distinctly aware of our urgent need to transform trauma care. This is our challenge: to build a stronger knowledge base, to increase our capacity to adapt practices to different cultures and settings, and to ensure that all systems that work with children and their families are trauma-informed in the services they provide. This is a challenge to which the National Child Traumatic Stress Network is so ably responding. Thanks to the many people in this room, we are developing trauma care practices that can change the course of the life of a traumatized child.
As I began to prepare my remarks for this talk, I thought some more about why the work of this Network is so important to the future of children’s mental health. An old quote from Franklin Delano Roosevelt crossed my mind. Back in 1936, our Nation was reeling from the Great Depression and the Dust Bowl—or what you could call both human-made and natural disasters. Millions of families suffered deeply—from poverty and hunger, from lost jobs and homes, and from a lost sense of security and hope in their future.
[SLIDE 3. Depression photo]
President Roosevelt looked at the suffering of children and said in challenge, “Youth comes to us, wanting to know what we may propose to do about a society that hurts so many of them.”
His words made clear to me the importance of the National Child Traumatic Stress Network. The Network is one way we are answering youth’s question.
[SLIDE 4. Network mission]
This is the mission of the Network: “To raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States.” The Network is helping children, families, and communities recover from past traumas and build resilience to face life’s future challenges. Its members are reaching out to other systems to educate them about trauma and its consequences and to engage them in reducing its impact.
Through this Network, the Substance Abuse and Mental Health Services Administration (SAMHSA) is making incredible progress toward our objective: to stimulate the development of community-based systems of care that are trauma-informed. These networks will encompass all the systems involved in the mental health of children and families, such as education and child welfare, so that any door becomes the right door for prevention, early intervention, support, and treatment.
The prevalence of trauma in the United States presents us with an incredible challenge. Trauma is pervasive throughout our society. It affects persons of every gender, race, age, and economic class. According to the U.S. Department of Justice, nearly one-and-a-half-million women are raped and physically assaulted by an intimate partner each year. About nine hundred thousand men suffer similar abuse. Twenty thousand adults and children are murdered each year. In this country, a child is a homicide victim every 2 hours! A child is reported to be neglected, or physically or sexually abused, every 10 seconds.
A child doesn’t have to suffer trauma physically to experience its effects. Witnessing trauma can hurt as deeply as any blow. A teenager seeing his friends fall victim to street violence, a young girl watching her mother being abused repeatedly, a small child overwhelmed by the loss or absence of a parent—each experience can cause acute traumatic stress in a child.
A child also can experience traumatic stress from environmental causes, such as natural disasters. There is no stronger or more painful example of how many lives can be affected by a single event than the recent tsunami. The number of people believed killed by this natural disaster is nearly 300,000. The number of lives tragically affected by this loss is far greater. Millions of adults and children in South Asia and elsewhere are struggling to cope with the residue of fear, anger, guilt, helplessness, and grief.
[SLIDE 5. Tsunami orphans]
Nearly one-and-a-half-million children lost their homes; many of these children are now orphans. Imagine the anguish! In one brief moment, these children lost everything and everyone that represented their security.
Research has documented well the strong association between trauma and mental disorders. Consequently, we know that the psychological aftermath of the tsunami will be both profound and long-lasting. I’m gratified that experts from the Network are providing information to their international colleagues who are responding to this tragedy. SAMHSA also is providing affected countries with information and assistance. Many of you know Robert DeMartino, the first director for the child trauma program. Commander DeMartino currently is on leave from SAMHSA, having been deployed to Indonesia aboard the USS Mercy.
The international tsunami relief effort demonstrates a critical challenge that we face in expanding trauma-informed care for children. Concepts of mental health differ by race and culture, as do strategies for coping and healing. We see these differences within our own country, such as within our Latino, Asian, and Native American communities. In working with different cultures both here and abroad, we need to share information in ways that enable others to use this information effectively. Ideally, they will be able to merge our best practices with the cultural strengths they already have.
[SLIDE 6. List of traumatic experiences]
As this slide indicates, children can be exposed to a staggering variety of traumatic experiences. And yet, childhood is supposed to be a time for children to learn, to dream, and to grow strong in a belief in themselves and the possibilities of life. It is supposed to be a time for them to start building a successful adulthood on the solid foundation of their youth. What may happen to children when trauma shatters their foundation?
Until recently, we believed the effects were mostly psychological. New brain imaging techniques, however, show that some traumas—such as childhood physical and sexual abuse—can cause permanent damage to the neural structure and functioning of the developing brain. This damage can seriously impair a child’s lifetime ability to cope with additional trauma and even with life’s daily stresses.
Even without neural damage, the psychological consequences of childhood trauma can be widespread and long-term. Research links childhood trauma to substance abuse, poor school performance, impaired emotional and physical development, and the inability to form healthy relationships. As noted in Mental Health: A Report of the Surgeon General,
[SLIDE 7. Surgeon General quote]
“From early childhood until death, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem. These are the ingredients of each individual’s successful contribution to community and society.”
Consequently, any experience that undermines the sound mental health of children can prevent them from attaining their full potential and leading a full life in their communities.
We must keep in mind, however, that children exposed to trauma—even repeated trauma—may not develop a social, emotional, or behavioral disorder. We shouldn’t assume that every child who experiences a trauma will develop symptoms; otherwise, we’ll end up labeling, undermining, and focusing on the negative aspects of a traumatic event. What’s more, there is a range of expected reactions depending on a child’s prior exposure to trauma, developmental stage, and genetic factors. Strong reactions to trauma are normal. We need to help children understand the depth of their emotional reactions so they and their families don’t misinterpret deeply felt emotions as signs of traumatic disorder.
There is a balance that must be struck: a balance between over-pathologizing traumatic experiences and ensuring that children and their families receive necessary treatment as early as possible. Eighty percent of children with a history of exposure to a traumatic event do not experience a psychiatric disorder. Most children have a supportive environment and good mental health. In addition, many children get through traumatic experiences with their mental health intact because they have so many other strengths.
[SLIDE 8. Werner quote]
I believe in the power of resilience, which is rooted, of course, in the quality of hopefulness. To quote Dr. Emmy Werner, one of the earliest resilience researchers, “Protective buffers. . . seem to be helpful to us as members of the human race . . . . [They] appear to make a more profound impact on the life course of individuals who grow up and overcome adversity than do specific risk factors.” Part of the work in addressing trauma is to find out more about resilience and self-righting capacities. We need to know better how we can instill them in children, families, and communities at risk.
I credit the Network for a great deal of the progress being made in transforming trauma care. The recently published Children and Trauma in America: A Progress Report of the National Child Traumatic Stress Network is a must-read for people who work with children and families. This report is both a summary of the state-of-the-art in trauma care as well as an indication of the future work that the Network can accomplish. As Doctors Robert Pynoos and John Fairbank proudly wrote in the report, “The vitality and commitment of our Network partners, coupled with their humanity and scientific rigor, provide a sterling foundation for continued progress over the years ahead.” No Fortune 500 president could wish for anything better to say in a company’s annual report to its stockholders. Thank you personally for your contributions to a field of practice that will affect the lives of children profoundly.
Much of the work being done by the Network reflects a larger goal of transforming all mental health care in America. The concept of mental health transformation originated with the report called Achieving the Promise: Transforming Mental Health Care in America. You will have received a copy of the report in your conference materials.
This report, released nearly 2 years ago by the President’s New Freedom Commission on Mental Health, is a critical assessment of our national mental health system. The report describes a system in disarray. Services and supports are fragmented, disconnected, and often inadequate. Instead of ready access to quality care, the system presents barriers to recovery. The report recommends nothing less than a fundamental transformation of our Nation’s approach to mental health care.
Now, transformation is an enormous concept in and of itself. Achieving the Promise does not define transformation, nor does the report describe the processes or benchmarks for achieving it. Instead, the report presents transformation as a vision, a process, and an outcome all tied to one overarching goal. That goal is a mental health system that facilitates recovery and resilience in the lives of the children and adults it serves.
A paper on the “Concepts of Transformation,” written by Dr. Noel Mazade for the National Association of State Mental Health Program Directors Research Institute, offers some insight into the meaning and processes of transformation. In defining transformation, Dr. Mazade includes this analysis by the National Learning Infrastructure Initiative.
[SLIDE 9. Defining transformation]
It reads, “In some ways, transformation is a fancy word for change. But [transformation] does imply a certain type of change—one that makes a sharp break with past practices and that ushers in a new set of assumptions and values about the institution. It suggests a structural, procedural, and even cultural makeover of huge proportions with long-term consequences.” This definition certainly describes what the Network hopes to achieve through its collaboration and community outreach related to trauma care.
Achieving the Promise presents us with 6 broad goals and 19 more specific recommendations for a transformed mental health system. These are the goals.
[SLIDE 10. Six goals]
Goal 1. Americans understand that mental health is essential to overall health
Goal 2. Mental health care is consumer and family driven
Goal 3. Disparities in mental health services are eliminated
Goal 4. Early mental health screening, assessment, and referral to services are common practice
Goal 5. Excellent mental health care is delivered and research is accelerated
Goal 6. Technology is used to access mental health care and information
As you can see, the work of the Network strongly reflects the goals of Achieving the Promise. Consider Goal 5.
[SLIDE 11. Goal 5 and recommendations]
Goal 5 is that excellent mental health care is delivered and research is accelerated. Currently, there are 54 centers in the Network, including universities, community-based mental health centers, hospitals, and clinics. This unique collaboration is bringing together two essential partners for progress. One is the academic community, with its specialized knowledge and experience in developing evidence-based treatments. The other is providers, with the wisdom developed in providing direct care to traumatized children and their families. Treatment is transformed when science and service learn from each other!
The Network has created a productive, collaborative, and innovative structure, with the potential to accelerate the development and distribution of effective treatment practices. In addition, the Network is helping to develop the knowledge base about trauma. As you can see from this slide, reducing the impact of trauma is seen as critical to the achievement of Goal 5. In fact, Achieving the Promise identified trauma as one of the four major understudied areas of mental health.
Dr. Fairbank was kind enough to share an anecdote with me that touches upon changes needed to achieve nearly all of the goals. This story was sent to Dr. Fairbank by Dr. Richard Vandenpol, principal investigator for the Montana Center for the Investigation and Treatment of Childhood Trauma. The story describes the challenge—as well as the necessity—of adapting trauma care to the special needs of a child, such as a child with disabilities. These children are more vulnerable to certain forms of trauma, such as abuse, yet their traumatic stress often goes undiagnosed and untreated. Many professionals who work with children with disabilities are unfamiliar with the signs of trauma, confusing trauma symptoms with the disability. Many practitioners simply don’t feel prepared to treat their mental health needs. Thankfully, the Network is striving to develop treatments that are child-specific and can be applied across service systems.
My story is about “Sarah,” a little girl whose developmental delays affected her ability to communicate verbally. Instead, she used simple sign language and gestures. At age 3, Sarah began riding a school bus to an early education program. Sarah traveled contentedly for several months, but then she began to scream and cry whenever she was buckled into her seat. She repeatedly touched her genitals. She began to vomit deliberately.
On the advice of her counselor, her parents persisted in busing her to school to discourage her from using temper tantrums as a means of communicating her feelings. But Sarah was communicating. Her distress was the language of trauma, and no one was trained to interpret her distress. Eventually, as a result of a physical checkup and a subsequent investigation, the reason for Sarah’s distress became apparent. Sarah was being sexually abused repeatedly by a school staff member.
Sarah is much older now, but she still is recovering from her traumatic experiences. At age 21, she remains uncomfortable with the notion of having a boyfriend. Her mother shared her story with the Network on one condition: that we use Sarah’s experience to engage others in protecting children like her.
Sarah’s mother asked that people who work with children be trained in the fundamentals of recognizing, preventing, and helping to treat childhood trauma. I am so proud that training is a key function of the Network. In 1 year, the Network trained more than thirty-nine thousand individuals in the treatment of traumatic stress. More than fifteen thousand persons were trained in traumatic stress assessment. We are keeping our promise to Sarah’s mother.
SAMHSA has made another promise that you also can help us keep. When we think about making other systems more trauma-informed, the subject of seclusion and restraint immediately comes to mind. For children who have experienced physical and sexual abuse, the use of coercive practices can trigger traumatic memories and deepen the wounds they already carry. In the words of SAMHSA Administrator Charles Curie, “This intervention—whether chemical or physical?is not a treatment at all. It is a product of treatment failure.”
Reducing and ultimately eliminating the use of seclusion and restraint is a top priority for SAMHSA. During the past few months, we have awarded grants to eight States to identify ways to reduce the use of these practices. We also have contracted with the National Association of State Mental Health Program Directors to manage a technical assistance center. The function of the center is to offer advice about alternative approaches to State mental health systems.
The elimination of seclusion and restraint falls clearly within the mission of the National Child Traumatic Stress Network. There are many ways you can collaborate with the association to help assess and disseminate information about best practice alternatives. I urge you to use this meeting to identify ways that you can support the association’s work.
The Network’s efforts and growth have brought about much success, as well as challenges. During the next few days, and in the weeks and months ahead, you will be exploring ways to build upon your collaborative efforts. These are some questions needing answers: How can the Network establish clear roles and expectations for collaborative efforts? How can it increase its national impact by working with groups beyond the immediate circle of grantees, such as the National Association of State Mental Health Program Directors? How can it ensure the sustainability of community activities even after Federal grant cycles are completed?
Federal grants are intended to be catalysts for change, rather than long-term support for any one group. SAMHSA is a small agency with a large mission, so we must use our funding strategically to stimulate transformation as broadly as possible. For us, transforming trauma care for America’s children and families means this: sharing our limited funding with new groups in new locations until every community nationwide develops the capacity and the political will to support trauma-informed mental health services. We anticipate that those groups that already have received funding can accelerate this process by serving as models of transformation.
As a former State director and a former community service provider, I understand the work involved in sustaining program impact beyond Federal funding limits. Sustainability, however, is a key element of transformation—making sure that new behaviors and new competencies become embedded through the process of change. The purpose of transformation, after all, is to enable us to do now what we were unable to do before.
The Network provides vital services to children and communities nationwide. More than forty-two hundred children are treated by Network members each month! It is time for the communities themselves to help sustain these services. Community-based child welfare, juvenile justice, education, and other systems working with children and their families should be collaborators both within and outside of the Network. This is transformation!—to ensure that a better system of care will take root in a community and then grow within that community.
SAMHSA will support the Network’s efforts toward sustainability by assessing its contributions to children’s mental health. We have a responsibility to Congress and to the people we serve to ensure that our investments in mental health care generate significant and positive outcomes for consumers.
As you know, we have just launched a cross-site evaluation of Network members to evaluate the effectiveness of the Network as a whole, including its ability to serve as a national resource capable of improving children’s access to high-quality, trauma-informed mental health services. Our study will:
- Describe the children and families served by the Network and their outcomes
- Assess the development and dissemination of effective treatments and services
- Evaluate intra-Network collaboration
- Assess the Network’s broader impacts across systems.
We will use the information we collect to inform others about the value of transformed trauma care for children, families, and communities.
[SLIDE 12. Vision from Achieving the Promise]
In my view, the Network is an example of transformation in action. The Network shows that we can—and are—moving toward the promise of mental health transformation. This promise is “a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life will have access to effective treatments and supports—essentials for living, working, learning, and participating fully in the community.”
I urge you to spend the next 3 days exploring your continued potential to make this promise real. Share. Learn. Grow. Rejuvenate your faith in the incredible human capacity for change.
Our children are growing up in a world made uncertain by its staggering potential for violence, both from nature and from other people. We must continue our work to develop better methods of reducing the impact of trauma. Together, we can develop and share evidence-based practices across service systems. Together, we can bring about needed changes in trauma-informed care. We can help children heal, and we can help them build resilience to face life’s future challenges.
[SLIDE 13. Roosevelt quote]
To again quote President Roosevelt, “We cannot always build the future for our youth, but we can build our youth for the future.” I know I can count on you to continue making a profound difference in the lives of our children. Thank you.
