[Senate Hearing 113-527]
[From the U.S. Government Publishing Office]
S. Hrg. 113-527
PROTECTING OUR CHILDREN'S MENTAL HEALTH: PREVENTING AND ADDRESSING
CHILDHOOD TRAUMA IN INDIAN COUNTRY
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HEARING
before the
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
NOVEMBER 19, 2014
__________
Printed for the use of the Committee on Indian Affairs
______
U.S. GOVERNMENT PUBLISHING OFFICE
92-529 PDF WASHINGTON : 2015
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COMMITTEE ON INDIAN AFFAIRS
JON TESTER, Montana, Chairman
JOHN BARRASSO, Wyoming, Vice Chairman
TIM JOHNSON, South Dakota JOHN McCAIN, Arizona
MARIA CANTWELL, Washington LISA MURKOWSKI, Alaska
TOM UDALL, New Mexico JOHN HOEVEN, North Dakota
AL FRANKEN, Minnesota MIKE CRAPO, Idaho
MARK BEGICH, Alaska DEB FISCHER, Nebraska
BRIAN SCHATZ, Hawaii
HEIDI HEITKAMP, North Dakota
Mary J. Pavel, Majority Staff Director and Chief Counsel
Rhonda Harjo, Minority Deputy Chief Counsel
C O N T E N T S
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Page
Hearing held on November 19, 2014................................ 1
Statement of Senator Barrasso.................................... 3
Statement of Senator Begich...................................... 4
Statement of Senator Cantwell.................................... 3
Statement of Senator Franken..................................... 7
Statement of Senator Heitkamp.................................... 7
Statement of Senator Murkowski................................... 6
Statement of Senator Tester...................................... 1
Witnesses
Boerner, Vernee, President/CEO, Alaska Native Health Board....... 28
Prepared statement........................................... 30
Enomoto, Kana, Principal Deputy Administrator, Substance Abuse
and Mental Health Services Administration...................... 19
Prepared statement........................................... 20
Listenbee Jr., Hon. Robert L., Administrator, Office of Juvenile
Justice and Delinquency Prevention, U.S. Department of Justice. 8
Prepared statement........................................... 10
Roubideaux, Hon. Yvette, MD, MPH, Acting Director, Indian Health
Service........................................................ 14
Prepared statement........................................... 15
van den Pol, Rick, Ph.D., Director and Principal Investigator,
Institute of Educational Research and Service, the University
of Montana National Native Children's Trauma Center............ 25
Prepared statement........................................... 27
Appendix
Forquera, Ralph, Executive Director, Seattle Indian Health Board,
prepared statement............................................. 45
Keita, Gwendolyn Puryear, Ph.D., Executive Director/Public
Interest Directorate, American Psychological Association,
prepared statement............................................. 49
Mathur, Rricha, Policy Research Associate/Program Manager, First
Focus, prepared statement...................................... 46
National Indian Child Welfare Association (NICWA), prepared
statement...................................................... 50
Response to written questions submitted to Vernee Boerner by:
Hon. Mark Begich............................................. 62
Hon. Jon Tester.............................................. 60
Response to written questions submitted by Hon. Jon Tester to
Rick van den Pol............................................... 58
Written questions submitted to:
Kana Enomoto................................................. 63
Hon. Robert L. Listenbee, Jr................................. 64
Hon. Yvette Roubideaux....................................... 65
PROTECTING OUR CHILDREN'S MENTAL HEALTH: PREVENTING AND ADDRESSING
CHILDHOOD TRAUMA IN INDIAN COUNTRY
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WEDNESDAY, NOVEMBER 19, 2014
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:30 p.m. in room
628, Dirksen Senate Office Building, Hon. Jon Tester,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
The Chairman. I will call this hearing of the Senate Indian
Affairs Committee to order.
This will be my last hearing as Chairman, hopefully for the
short term, but the bottom line is I just want to thank the
staffs of both the Majority and Minority for the work they have
done.
We would not get a lot done around here if it wasn't for
our staffs. I just want to say I appreciate their commitment to
Indian Country.
It has been great in my short tenure as Chairman of this
Committee to be able to get around and see some of the
challenges out there. As was pointed out to me when I was first
elected to the United States Senate, the challenges in Indian
Country are many. There are so many that it really does take a
bipartisan effort to get those solved.
I think this Committee has worked traditionally in a fairly
good bipartisan way. We have some opportunities during this
lame duck to get some stuff done for Indian Country and
hopefully that will happen. Whether it is in the area of
health, water, housing, police protection or whatever, these
are very important issues.
To get down to the business at hand, I have been able to
spend some time in Indian Country speaking with tribal leaders,
hearing from concerned tribal members, and visiting
celebrations and ceremonies that keep Indian Country alive and
vibrant.
I must say I have enjoyed the time I spent in those
communities. The diversity of Indian Country and the value that
Indian Country places on its children to protect them and
helping them to become future leaders for their people.
It is often said that children are our most precious
resource. Nowhere is this more visible than in tribal
communities I have visited.
Yet, some disturbing realities persist. Studies show that
Native children suffer from high rates of trauma, abuse and
exposure to violence. They grow up in poverty at levels much
higher than our non-Native counterparts. These children are
exposed to a cycle of trauma that I think we need to address
together to break.
Earlier this week, the Department of Justice released a
report entitled Ending Violence So Children Can Thrive, which
outlined recommendations for addressing children exposed to
violence. This report represents tireless research and work in
the field of preventing childhood trauma and promoting
resiliency in early childhood.
Both are crucial to building strong communities. Both will
be vital in the future of our Native children. It is precisely
reports like this with recommendations from tribal people that
we need to see.
However, as we know all too well, it is more than words on
paper that our children need. We need to turn these
recommendations into actions, put safeguards in place for our
most vulnerable community members.
There are tremendous studies on brain research, some of
which we will hear about today, that show us how a child's
brain development, social and emotional development are
compromised when there are repeated and significant instances
of fear, neglect and anxiety.
A 2008 report by the Indian Country Child Trauma Center
calculated that Native youth are two-and-a-half times more
likely to experience trauma when compared to their non-Native
peers. This is preventable.
We have the power to ensure our children grow up in safe
and supportive environments. We have the power to help support
healthy and appropriate development and make it possible for
our children to thrive. My hope is that is our focus today.
We have heard what is wrong. Now we need to hear what we
need to do to make it right, what we need to do to make it
right by our children. That should be the most important
question we ask and that is the question I know hard working
folks in Indian Country are asking themselves every day.
I look forward to this hearing from the Administration,
education and tribal leaders who are here today about how
issues of childhood trauma impact their respective agencies and
communities and what we, as policymakers, can do better to help
protect and promote resiliency among our Native children.
As many of you have noticed, we originally scheduled two
panels but we have one now because we have a vote a number of
votes at 3 o'clock. We shortened the time frame to be able to
give us a few more minutes for questions.
With that, I would be remiss if I did not recognize the
Vice Chairman, with whom it has been a pleasure to serve with
over the past almost a year. With that, you can give your
opening statement, Senator Barrasso.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you, Mr. Chairman.
I just want to say how much I appreciate your leadership.
You have been committed to Indian issues your entire career in
the Senate, even more so as Chairman. The Montana tribes have
benefitted greatly from your work.
I want to thank you for your work and ask you all to join
me in thanking the Chairman as this is his final hearing.
I also want to tell you that I appreciate you holding this
hearing. I agree with your very thoughtful comments.
According to the Indian Health Service, childhood trauma is
disproportionately experienced by Indian children. The reasons
are multi-factorial, related to recurrent abuse, accompanied
with high incidences of alcohol and drug abuse, suicide,
violence and according to substance abuse and mental health
services of the Administration, the death of family members can
also be a significant cause of childhood trauma.
These factors are particularly acute on the Wind River
Reservation in Wyoming. The Indian Health Service has informed
this Committee that the average age of death on the Wind River
Reservation in Wyoming is 49 years of age.
Alcohol-related injuries have been cited by the Indian
Health Service as a significant contributing factor for the
premature death rate. This is a sensitive matter and one that
will require active participation from multiple disciplines and
agencies to address.
The Attorney General has established an advisory committee
to his Task Force on American Indian and Alaska Native Children
Exposed to Violence. The advisory committee was charged with
examining this exposure to violence and providing
recommendations on how to address the issue.
Yesterday, the advisory committee issued its policy
recommendations to the Department of Justice so I look forward
to examining how those recommendations will address and prevent
trauma to Indian children.
I want to thank the witnesses and look forward to your
testimony.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Barrasso.
Are there other opening statements? Senator Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Mr. Chairman.
I too want to applaud your leadership. As Chairman of this
Committee, you have certainly worked to improve economic
opportunities, schools and obtain greater access to health care
for tribal communities.
We certainly will look forward to working with you in the
new Congress in your capacity to continue to work on these
issues.
I certainly come to this hearing with still a heavy heart
but am very thankful that you are having this hearing. As many
know, Washington State suffered a devastating tragedy last
month at the Marysville Pilchuck High School that took the
lives of five students, including the shooter.
Three of those shooting victims were members of the Tulalip
Tribe of Washington. Across Washington and across tribal
communities, we continue to mourn this incredible tragedy.
We will never know what exactly led to this senseless
violence but it is a deadly and urgent reminder that we must do
more to ensure the mental health system can help diagnose and
treat young people when they need help.
The Marysville shooting is tragic proof of an alarming
statistic. According to the Department of Justice, assaults,
homicide and suicide account for 75 percent of the deaths of
American Indians and Alaska Natives between the age of 12 and
20. This is unacceptable.
A robust mental health infrastructure is one key piece
necessary to prevent these tragedies in the future. To that
end, I would like to hear from the panelists how we can better
integrate mental health and primary care services to make sure
young people are not just turned away when they seek care.
The State of Washington is revamping its Medicaid delivery
system to merge behavioral health and primary health care
services by 2020. I would like to know what the Indian Health
Service is working on to also integrate those kinds of
behavioral health and primary care.
Unfortunately, data on the issues of psychiatric services
available in Indian Country and data on the shortage are not
widely available but a recent survey from Indian Health
Services found there were only 950 psychiatric beds to serve
all tribal communities across the United States of America.
We have to do better, Mr. Chairman. Thank you so much for
this important hearing.
The Chairman. Are there other opening statements? Senator
Begich?
STATEMENT OF HON. MARK BEGICH,
U.S. SENATOR FROM ALASKA
Senator Begich. Mr. Chairman, I want to thank you for
having this important hearing.
To Vernee, thank you for being here all the way from
Alaska. We appreciate it. Hopefully we will hear some positive
and encouraging testimony on what we can do better.
Mr. Chairman, this is going to be my last meeting also in a
different way. I just want to say thank you and also to Senator
Akaka who was here originally when I came and Senator Cantwell
who chaired this Committee.
We did a lot of work on Alaska issues, the Nation's First
People issues and spent a lot of time in this Committee talking
about the importance of a variety of issues that are important,
not only to Alaska, but really across the country. It has been
an honor to be here.
As mentioned, the Attorney General's Advisory Committee on
American Indian and Alaska Native Children Exposed to Violence,
that important report has now been released. It has incredible
information for us, including the work by Val Davidson, Bethel
and many others who have spent the time to help us understand
what more we can do.
Mr. Chairman, I want to thank you for helping to move
forward one piece of legislation, our Safe Families and
Villages Act, something I worked on for the last six years. We
were trying to get unanimous consent. I understand on the
Democratic side there is not a problem but on the Republican
side, there is.
We have redrafted and hopefully the Republicans will look
at this. We have streamlined it and hope to again hotline a
different version tonight that streamlines it and resolves the
concerns that the Republicans have on this issue.
It is an important piece. When we passed VAWA, Alaska
Native people were left out. All we want to do is fix it for
Alaska Native people. That is all.
Half the tribes of the Nation are from Alaska, not by
population but by tribes. It just seems fair that we want to
fix it for all first people of this country, not just the lower
48.
Even though I would prefer a more robust Safe Families and
Villages Act, we have streamlined it and cleaned it up to meet,
I believe, the minority's objections. Hopefully they will see
it tonight and agree to hotline it as it is an important piece
for Alaska.
Let me also say, Mr. Chairman, the work that is still ahead
of this Committee I will not be a part of obviously, but it is
enormous. The first people of this country, from Alaska Natives
to the first people of the lower 48 and Hawaiian Natives are
important. Many times they are forgotten in the issues with
which we deal with.
Sometimes we pass great legislation and then forget there
are also the first people who are touched by what we do. I
would encourage this body as they move forward that not only is
it important to discuss these issues here in this Committee,
but as we talk on the floor of the Senate and other committees
we sit on, that we discuss the importance of the first people
of this country.
Again, I am hopeful that the one remaining piece I think
would create equity for Alaska Native people will hopefully be
resolved tonight. We will see.
I want to thank the Chairman and lastly, all the staff. The
staff does incredible work for us. Sometimes we get to say all
kinds of stuff in this forum but at the end of the day, it is
the people who sit on the walls behind us that do an enormous
amount of work and make sure the issues we care about are
brought to the forefront and also help us make sure we get
bipartisan support to get things done.
Mr. Chairman, I want to thank you for the opportunity and
past chairmen who have been here and given me the chance to
talk about Alaska issues.
Thank you.
The Chairman. Senator Begich, I would just say you and I
serve on a lot of the same committees in the United States
Senate. I just want to thank you for all your work and
dedication, especially to Indian Country. Bringing the Alaska
perspective has been critically important as we look to serve
all our Native American challenges.
Are there other opening statements? Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman.
I apologize that I was not able to hear not only the other
statements from colleagues but particularly that of my
colleague from Alaska.
I want to take this opportunity to thank him for his
leadership on these issues that we both agree are critically
important to the Native people of our State and not just the
Native people of our State because I think we recognize that
our Alaska Native communities really represent what is the
heart of Alaska.
We see that come together at the annual convention and at
the Alaska Federation of Natives. We see it when we are out in
the villages, villages that I think face some of the most
difficult living conditions anywhere in this country.
When you look at the cost, when you think of the
environment and the social factors that are against them, yet
there is resilience, a strength and a beauty in these people
that is to be celebrated.
I appreciate the efforts that he has made on so many of
these issues, working together and talking about the Safe
Families and Villages Act, something that we have been working
on for a period of years and our staffs have shared initiative
on that.
He mentioned that there has been resistance on the
Republican side of the aisle. That is correct. There are those
who have waited to hear the comments coming back from the
Department of Justice on this. We are still waiting on that. It
has made it complicated.
I have committed to him, as I have committed to Alaskans,
that one of the things we can do most certainly at this point
in time is to repeal Section 910 of VAWA, absolutely Alaska-
specific there, but I think an effort that goes a long way in
ensuring that there is a level of equity for some of the most
vulnerable.
We will certainly work on that and I am happy to take a
look at the streamlined version that he just mentioned.
I also want to acknowledge the work of Senator Heitkamp.
The hearing we are having today focusing on the mental health
needs of our children within Indian Country, the leadership
that has been demonstrated focusing on our Native children in
the lower 48 as well as Alaska Natives, I think has stepped up
the review to a point I have not seen in the 12 years I have
been serving on this Committee.
I think it is because of the doggedness of the Senator from
North Dakota in focusing on this. I am pleased that we have
been able to move forward the Children's Commission.
We see too clearly in the statistics the impact of child
abuse, of neglect, of trauma and see that not only with the
children but as these children grow to be contributing members
of society, to become parents and knowing that trauma is not
limited to that instance and how that ripples across our
families and across our communities.
We have some very, very troubling statistics in Alaska. Our
Alaska Native Tribal Health Consortium Epidemiology Center has
estimated that 75 percent of Alaska Native people have
experienced adverse childhood experiences.
Senator Begich was with us in Fairbanks last year at the
AFN convention when a group of young people from the village of
Tanana took to the center stage of a convention of 4,000-5,000
people and basically said, we have had enough. We are tired of
adults who are abusive, we are tired of the drinking, we are
tired of the drugs, we are tired of adults who are not role
models, and we are tired of the violence.
When it takes our young people to shame the grownups into
action, we darned well better be paying attention. I thank
those who have joined us, those who have traveled far. Ms.
Boerner, thank you.
I also recognize we are going to have a whole series of
votes. I don't know how we are going to get through this
critically important hearing and get all the information out on
the table but I thank you for having it, Mr. Chairman.
The Chairman. Thank you.
Senator Heitkamp.
STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Very quickly, none of us can escape the
statistics. They are out there every day. Now we have the most
recent report but very few of us have lived those statistics.
I have met people who have. The President has met people
who have. People on this Committee have met the living and
breathing examples of those statistics.
If we, the powerful government of the United States, cannot
protect the poorest, most disenfranchised and most vulnerable
of all people, then we are not worthy of the seats we are
sitting in. We are not worthy of where we are right now.
This will be our unending commitment. I want to thank my
good friend, Senator Murkowski from Alaska, for sharing this
burden with me. I came here knowing this was going to be among
my highest priorities because I have seen the faces of those
statistics and they will haunt me. They haunt anyone who really
opens their eyes.
What you do is so important. I know the trauma you
experience as first responders. I know that trauma because I
have seen it. Thank you because you share that burden every day
and you share the love for children. Hopefully you will share
with us the solutions today.
Thank you so much.
The Chairman. Senator Franken.
STATEMENT OF HON. AL FRANKEN,
U.S. SENATOR FROM MINNESOTA
Senator Franken. I want to associate myself with all the
statements I have heard so far and thank Senator Begich.
I want to hear your testimony. I am sorry because of the
votes, I would like to have this hearing again because I know
we are not going to be able to do questions and answers. I will
submit questions for the record but I want to get to your
testimony.
I just want to associate myself with the three Senators I
just heard and especially thank Senator Begich for his service
and his friendship.
The Chairman. Thank you, Senator Franken and thank you all
for your statements.
I don't know how this is going to work. We are going to
listen to your opening statements and if we are pulled away, we
may try to roll it for a while. Sometimes that works, sometimes
it does not. We will see how it goes and see if we can get some
Q and A in. Otherwise, the questions will be put forth in the
record. The question will be in writing for you to answer at a
later point in time and we will get them as part of the record.
I want to welcome our panelists. First, we have Robert L.
Listenbee Jr., Administrator, Office of Juvenile Justice and
Delinquency Prevention, U.S. Department of Justice. I also want
to welcome back a friend of the Committee, Dr. Yvette
Roubideaux, Acting Director, Indian Health Service.
We have Kana Enomoto, Principal Deputy Administrator,
Substance Abuse and Mental Health Services Administration; Rick
van den Pol, Director and Principal Investigator, Institute of
Educational Research and Service, The University of Montana.
This institute houses the National Native Children's Trauma
Center and I want to thank you for traveling a distance to be
here, Rick. Finally, we welcome Ms. Vernee Boerner, President
and CEO, Alaska Native Health Board in Anchorage, Alaska.
Talking about a trip to come see us, thank you very much,
Vernee.
I would remind the witnesses to try to keep your testimony
to five minutes and know that your full written testimony will
be a part of the record.
We will start with you, Robert.
STATEMENT OF HON. ROBERT L. LISTENBEE JR.,
ADMINISTRATOR, OFFICE OF JUVENILE JUSTICE AND
DELINQUENCY PREVENTION, U.S. DEPARTMENT OF JUSTICE
Mr. Listenbee. Thank you, Mr. Chairman.
Chairman Tester, Vice Chairman Barrasso, and other
distinguished members of the Committee, I want to thank you for
the opportunity to discuss childhood trauma in Indian Country.
The Department is committed to working with American Indian
and Alaska Native communities and our partners to implement
evidence-based approaches to preventing and addressing
childhood trauma.
As the Administrator of the Office of Juvenile Justice and
Delinquency Prevention at the Department of Justice, Office of
Justice Programs, I oversee programs that provide direct
assistance and services to American Indian and Alaska Native
youth.
We work closely with tribal leaders, tribal elders and
organizations to develop programs that take into account Native
culture and practice.
Prior to my appointment as the OJJDP Administrator, I
served as a public defender and trial lawyer for nearly 30
years and dedicated myself to seeking justice for youth
involved in the juvenile justice system.
I represented hundreds of children and learned that many of
the youth entering the juvenile justice system were likely
exposed to some form of violence as children. More than 60
percent of kids in America encounter some form of violence,
crime or abuse ranging from brief encounters as witnesses to
serious violent episodes as victims.
As co-chair of the Attorney General's Task Force on
Children Exposed to Violence, in 2012, the task force issued a
final report containing comprehensive policy recommendations
aimed at reducing children's exposure to violence and enhancing
resiliency among affected children.
One of the primary recommendations was the establishment of
a separate task force to address the significant problem of
children's exposure to violence in American Indian and Alaska
Native communities, recognizing the unique government-to-
government relationship between the United States and tribes.
The Attorney General's Task Force on American Indian and
Alaska Native Children Exposed to Violence, created in 2013,
consisted of two components, the advisory committee and Federal
working group. The department just received the recommendations
from the advisory committee this week.
The advisory committee, co-chaired by Senator Byron Dorgan
and Ms. Joanne Shenandoah, held four hearings including one
held in Anchorage, Alaska, and six listening sessions
nationwide.
They learned that American Indian and Alaska Native
children experience various types of trauma at higher rates
than other children, trauma that ranges from physical abuse as
witnesses and victims to sex trafficking.
Alaska Natives are disproportionately affected by violent
crime and their children are therefore disproportionately
exposed to that violence. This difference can be attributed to
vast regional distances across the State, geographical
isolation, extreme weather, exorbitant transportation costs and
lack of economic opportunity and access to resources.
Compounding these high rates of violence is historical
trauma, a cumulative emotional and psychological wounding over
the life span and across generations.
The advisory committee discovered that some tribes and
urban Indian organizations have found ways to incorporate
tradition and develop resources to protect their children from
harm and help them heal. The integration of traditional healing
practices into mental health prevention and treatment for
Native children is essential.
In 2010, the Department of Justice launched its Coordinated
Tribal Assistance Solicitation in direct response to tribes
seeking a more streamlined, comprehensive grant process. CTAS
gives tribes the flexibility needed to better address their
criminal justice and public safety needs and funds initiatives
such as the tribal youth programs.
In fiscal year 2014, the department awarded CTAS grants to
169 American Indian tribes, Alaska Native villages, tribal
consortia and tribal designees. As part of the Attorney
General's Defending Childhood Initiative, OJJDP funded
initiatives in the Rosebud Sioux Tribe in South Dakota and the
Chippewa Cree Tribe at the Rocky Boy Reservation in Montana. I
describe these projects in my written testimony.
OJJDP is also funding efforts to enhance the capacity of
tribal healing to wellness courts to respond to alcohol-related
issues of tribal youth.
The National Institute of Justice in partnership with OJJDP
and OJP's Office of Victims of Crime is funding an effort to
more effectively assess exposure to violence and victimization
in American Indian and Alaska Native communities.
Mr. Chairman, I appreciate the opportunity to appear before
you today and I am prepared to respond to any questions you may
have.
[The prepared statement of Mr. Listenbee follows:]
Prepared Statement of Hon. Robert L. Listenbee Jr., Administrator,
Office of Juvenile Justice and Delinquency Prevention, U.S. Department
of Justice
Introduction
Chairman Tester, Ranking Member Barrasso and other distinguished
members of the Committee, thank you for this opportunity to discuss
childhood trauma in Indian Country. As Administrator of the Office of
Juvenile Justice and Delinquency Prevention (OJJDP) at the Department
of Justice's Office of Justice Programs (OJP), I oversee programs that
provide direct assistance and services to American Indian and Alaska
Native youth. We work closely with tribal elders, tribal leaders and
organizations to develop programs that take into account Native culture
and practice.
Prior to my appointment as the OJJDP Administrator, I served as a
public defender and trial lawyer for nearly 30 years and dedicated
myself to seeking justice for youth involved in the juvenile justice
system. I represented hundreds of children and made an important but
unsettling observation: many of the youth entering the juvenile justice
system were likely exposed to some form of violence as children. While
more than 60 percent of kids in America encounter some form of
violence, crime, or abuse, ranging from brief encounters as witnesses
to serious violent episodes as victims, \1\ limited research and
anecdotal evidence suggest rates of crime and violence, in some tribal
areas are higher. \2\
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\1\ OJJDP Children's Exposure to Violence: A Comprehensive National
Survey Bulletin, October 2009. https://www.ncjrs.gov/pdffiles1/ojjdp/
227744.pdf.
\2\ Perry, S.W., American Indians and Crime (pdf, 56 pages), A BJS
Statistical Profile 1992-2002, Washington, D.C. : U.S. Department of
Justice, Office of Justice Programs, Bureau of Justice Statistics,
December 2004, NCJ 203097.
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While serving as a Chief of the Juvenile Unit of the Defender
Association of Philadelphia, I co-chaired the Attorney General's Task
Force on Children Exposed to Violence. \3\ In 2012, the Task Force
issued a final report containing comprehensive policy recommendations
\4\ aimed at reducing children's exposure to violence and enhancing
resiliency among affected children. \5\ One of the primary
recommendations was the establishment of a separate Task Force to
address the significant problem of children's exposure to violence in
American Indian and Alaska Native communities in a way that recognizes
the unique government-to-government relationship between the United
States and tribes.
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\3\ In 2011, the Attorney General announced this Task Force as part
of the Attorney General's Defending Childhood Initiative, a project
that addresses the epidemic levels of exposure to violence faced by our
nation's children. http://www.justice.gov/defendingchildhood/task-
force-children-exposed-violence.
\4\ Shortly after the release of the Task Force report, the
Attorney general requested an Action Plan to implement the Task Force
recommendations. The Action was developed and approved in 2013. The
recommendations have been (and continue to be) acted upon by the
Department and our federal partners.
\5\ Listenbee, Robert L., Jr. et al., Report of the Attorney
General's National Task Force on Children Exposed to Violence,
Washington D.C.: U.S. Department of Justice, Office of Juvenile Justice
and Delinquency Prevention, December 2012.
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Attorney General's Task Force
In 2013, the Attorney General created the Task Force on American
Indian and Alaska Native Children Exposed to Violence. \6\ The Task
Force consisted of two components:
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\6\ Task Force on American Indian and Alaska Native Children
Exposed to Violence website: http://www.justice.gov/defendingchildhood/
task-force-american-indian-and-alaska-native-children-exposed-violence
An Advisory Committee composed of non-federal subject matter
experts who: (1) gathered information from public hearings,
written testimony, site visits, listening sessions, and current
research; and (2) used this information to draft a report to
the Attorney General that includes recommendations to
effectively address children's exposure to violence in Indian
Country. \7\
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\7\ It is noteworthy that while given their charge by the Attorney
General, the Advisory Committee felt strongly that the problems facing
children in American Indian and Alaska Native communities are so
significant that only concerted action by the Executive branch agencies
and Congress would begin to address them. Accordingly, they chose to
address their recommendations to entities beyond the Department of
Justice.
A Federal Working Group composed of federal officials from
key agencies including the Departments of Justice, Interior,
and Health and Human Services--who have experience with issues
affecting American Indian and Alaska Native communities. This
working group is in an ideal position to take steps to
implement policy and programmatic changes for the benefit of
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American Indian and Alaska Native children exposed to violence.
While the Department just received the recommendations from the
Advisory Committee this week, OJJDP has long been committed to
partnering with tribal governments to improve public safety in
communities and to building a better future for all young people.
The Advisory Committee, Co-Chaired by Senator Byron L. Dorgan and
Ms. Joanne Shenandoah, held hearings in four locations (Bismarck, ND;
Phoenix, AZ; Fort Lauderdale, FL; and Anchorage, AK) and six listening
sessions nationwide which brought together national, regional, and
local experts, solicited personal testimony, and provided a forum for
discussion on the effects of exposure to violence and promising
prevention and intervention strategies and programs. \8\ During the
hearings and listening sessions, the Advisory Committee learned that
American Indian and Alaskan Native children experience various types of
trauma at higher rates than other children--trauma that includes
physical abuse (as witness and victims), sexual abuse, domestic
violence, suicide, and victimization, and sex trafficking.
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\8\ American Indian and Alaska Native Children Exposed to Violence
Hearing Testimony: http://www.justice.gov/defendingchildhood/task-
force-hearings
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The Advisory Committee heard that Alaska Natives are
disproportionately affected by violent crime and Alaska Native children
are, therefore, disproportionately exposed to that violence. This
difference can be attributed to vast regional distances across the
state, geographical isolation, extreme weather, exorbitant
transportation cost, and lack of economic opportunity and access to
resources.
As one tribal leader told the Advisory Committee, ``For us . . .
the question is not who has been exposed to violence, it's who hasn't
been exposed to violence.'' \9\ Violence, including assaults, homicide,
and suicide, accounts for 75 percent of deaths of American Indian and
Alaska Native youth ages 12 to 20. \10\ These serious adversities often
lead to chronic and severe trauma. A recent report noted that tribal
children and youth experience posttraumatic stress disorder (PTSD) at a
rate of 22 percent. \11\
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\9\ Mato Standing High, Attorney General of the Rosebud Sioux
Tribe, quoted in Report of the Attorney General's National Task Force
on Children Exposed to Violence, Dec. 12, 2012, http://www.justice.gov/
defendingchildhood/cev-rpt-full.pdf. Full quote: ``For us in Rosebud,
our reservation, the question is not who has been exposed to violence,
it's who hasn't been exposed to violence.''
\10\ Dolores Subia BigFoot et al., ``Trauma Exposure in American
Indian/Alaska Native Children,'' Indian Country Child Trauma Center: 1-
4 (2008), available at: http://www.theannainstitute.org/
American%20Indians%20and%20Alaska%20Natives/
Trauma%20Exposure%20in%20AIAN%20Children.pdf
\11\ Deters, P. B., Novins, D. K., Fickenscher, A., & Beals, J.
(2006). Trauma and posttraumatic stress disorder symptomatology:
Patterns among AI/AN adolescents in substance abuse treatment. American
Journal of Orthopsychiatry, 76(3), 335-345.
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Compounding these high rates of violence in American Indian and
Alaska Native communities is historical trauma: a cumulative emotional
and psychological wounding over the life span and across generations.
The Advisory Committee found that the degree of violence in American
Indian and Alaska Native communities is directly related to historical
trauma and the impact of policies and practices that have proved
devastating to tribal communities. The testimony of the witnesses at
the hearings underscored the fact that Native Americans share a history
of displacement, forced assimilation, and cultural suppression, factors
that may contribute to child maltreatment.
Despite the epidemic levels of violence American Indian and Alaska
Native children are exposed to, the Advisory Committee discovered that
some tribes and urban Indian organizations have found ways to
incorporate tradition and develop resources to protect their children
from harm and help them heal. The Advisory Committee repeatedly heard
testimony indicating that programs for tribal children and youth,
including treatment and intervention programs, are most successful if
they are based on tribal customs, language, and spiritual ceremonies
that are deeply respectful of the traditional cultural values of the
child, family and tribe. \12\
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\12\ ``One of the main barriers both our youth and their families
face are professionals who have the proper credentials required by the
state but lack the cultural knowledge and ability or desire to even try
to understand where our children and their families are coming from.''
Darla Thiele, Director, Sunka Wakan Ah Ku Program Testimony before the
Task Force on American Indian/Alaska Native Children Exposed to
Violence Hearing in Bismarck, ND, December 9, 2014
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The Advisory Committee heard that integration of traditional
healing practices into mental health prevention and treatment for
Native children and youth is essential. Many of those who testified
recognized that, for American Indian and Alaska Native children and
their families, emotional and psychological well-being cannot be
separated from spiritual well-being. There is growing evidence that
Native youth who are culturally and spiritually engaged are more
resilient than their peers. \13\ For example, research has revealed
that over one third of Native adolescents and half of Native adults
prefer to seek mental health services from a cultural or spiritual
healer. \14\ In other research, American Indian caregivers preferred
cultural treatments for their children and found the traditionally
based ceremonies more effective than standard or typical behavioral
health treatment. \15\
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\13\ Gone, J.P., & Alcantara, C., ``Identifying Effective Mental
Health Interventions for American Indians and Alaska Natives: A Review
of the Literature,'' Cultural Diversity and Ethnic minority Psychology,
13(4), (2007): 356-363.
\14\ Grey, N., & Nye P. S., ``American Indian and Alaska Native
Substance Abuse: Co-Morbidity and Cultural Issues,'' American Indian
and Alaska Native Mental Health Research, 10(2), (2001): 67-82.;
Rieckmann, T. R., Wadsworth, M. E., & Deyhle, D., ``Cultural Identity,
Explanatory Style, and Depression in Navajo Adolescents,'' Cultural
Diversity & Ethnic Minority Psychology, 10(4), (2004): 365-382.;
Spicer, P., Novins, D. K., Mitchell, C. M., & Beals, J., ``Aboriginal
Social Organization, Contemporary Experience and American Indian
Adolescent Alcohol Use,'' Quarterly Journal of Studies on Alcohol,
64(4), (2003): 450-457.; Yoder, K. A., Whitbeck, L. B., Hoyt, D. R., &
LaFromboise, T., ``Suicide Ideation Among American Indian Youths,''
Archives of Suicide Research, 10(2).(2006): 177-190.
\15\ Walls, M. L., Johnson, K. D., Whitbeck, L. B., & Hoyt, D. R.,
``Mental Health and Substance Abuse Services Preferences Among American
Indian People of the Northern Midwest,'' Community Mental Health
Journal, 42(6), (2006): 521-535.
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OJJDP-Funded Efforts
In 2010, the Department of Justice launched its Coordinated Tribal
Assistance Solicitation (CTAS) in direct response to tribes seeking a
more streamlined, comprehensive grant process. CTAS gives tribes the
flexibility needed to better address their criminal justice and public
safety needs.
In Fiscal Year 2014, the Department awarded CTAS grants to 169
American Indian tribes, Alaska Native villages, tribal consortia and
tribal designees. The grants provide more than $87 million to enhance
law enforcement practices and sustain crime prevention and intervention
efforts in nine purpose areas including public safety and community
policing; justice systems planning; alcohol and substance abuse;
corrections and correctional alternatives; violence against women;
juvenile justice; and tribal youth programs.
As a part of the Attorney General's Defending Childhood Initiative,
OJJDP funded two initiatives that are tribally-directed and sensitive
to tribal traditions and culture. The Rosebud Sioux Tribe in South
Dakota delivers trauma-informed services, rooted in Lakota values that
address educational, justice system, and health-care needs. The
Chippewa Cree Tribe at the Rocky Boy reservation in Montana is
involving elders and youth from throughout the community in the design
of prevention and treatment programs that rely on traditional health
and healing methods. These are promising approaches that take into
account tribal customs aimed at enhancing resilience in affected
children, and they represent some of the exciting work already being
done to support children in tribal communities. Recently, leaders from
both tribes participated in a three-day training on indigenous
treatment for trauma offered by the National Native Child Trauma
Center.
OJJDP is funding efforts to enhance the capacity of Tribal Healing
to Wellness Courts to respond to alcohol-related issues of tribal youth
who are younger than 21. A Tribal Healing to Wellness Court is not
simply a tribal criminal or family court that orders individuals to
treatment. Rather, it is an innovative and collaborative legal process
that adapts the drug court concept and its key components to meet the
need of referred youth in a manner that respects and includes tribal
traditions. Under this initiative, participating courts are developing
or enhancing policy, procedure, assessment tools, or service models
that address underage drinking. A second component of the initiative
will deliver training and technical assistance to the participating
tribal courts. All programming is based on the 10 Key Components of an
effective Tribal Healing to Wellness Courts, modeled after policies
developed by the National Association of Drug Court Professionals.
Current funding supports five tribes--Yurok Tribe (CA), Lac Du Flambeau
Tribe of Lake Superior Chippewa Indians (WI), Southern Ute Indian Tribe
(CO), White Earth Nation (MN), Winnebago Tribe of Nebraska (NE)--and a
training and technical assistance provider. This program will be
expanded in Fiscal Year 2015 to support additional tribes.
Reaching children and families in tribal communities is a priority
for the National Center for Missing & Exploited Children (NCMEC).
NCMEC, which is funded by OJJDP, operates a national toll-free hotline
and serves as a clearinghouse and resource center that collects and
distributes data regarding missing and exploited children. NCMEC
collaborates with tribal leaders and communities to address pressing
issues such as multi-generational intra-familial sexual abuse, heavy
substance abuse across generations, and the sexual exploitation of
women and children. NCMEC is developing closer working relationships
with tribal communities and organizations to help identify and provide
resources and services to children and families living on tribal lands.
In 2014, NCMEC added a Tribal Law Enforcement Liaison to its staff to
help enhance collaboration with tribal law enforcement agencies; hosted
a Tribal Cultural Awareness training for staff; and worked with tribal
communities, schools and law enforcement to offer training.
Efforts like these, as well as OJJDP funding that goes towards
child advocacy centers, Internet Crimes Against Children (ICAC) task
forces, and our youth tribal portfolio, are important ways OJJDP is
working to prevent and address trauma in American Indian and Alaskan
Native communities and tribes.
Research
OJP's National Institute of Justice (NIJ), in partnership with
OJJDP and OJP's Office for Victims of Crime (OVC), is funding a 30-
month study intended to improve the health and well-being of youth in
American Indian and Alaska Native communities who may have been exposed
to violence and victimization. The study will develop and test a survey
instrument and different administration modes that can effectively
assess exposure to violence and victimization and determine the
feasibility of using these procedures in tribal communities and
settings. Although some research suggests higher rates of violence in
tribal communities, there has never been a national study of tribal
youth regarding their victimization experiences that provides reliable,
valid estimates of the scope of the problem. As a result, the exact
incidence, prevalence, and nature of victimization experienced by youth
living in tribal communities requires more research.
As part of the Attorney General's Children Exposed to Violence
Demonstration Program, NIJ has funded evaluations in two tribal
communities (i.e., Chippewa Cree and Rosebud Sioux Tribes) that include
a community survey addressing children's exposure to violence as well
as knowledge of and attitudes towards children's exposure to violence
and the prevalence of violence. Findings from these evaluations will
highlight the models used by Tribal Nations to prevent, treat, and
raise awareness about children's exposure to violence, emphasizing the
role of culture; discuss local challenges with implementing programs to
address children's exposure to violence; and provide recommendations
for other communities looking to prevent, treat, and raise awareness
about children's exposure to violence.
Responding to Victims
OVC is engaged in several initiatives in Indian Country. OVC has
responded to the challenge of helping service providers meet the needs
of drug-endangered youth in American Indian and Alaska Native
communities by producing a video series entitled, ``A Circle of Healing
for Native Children Endangered by Drugs.'' This series not only
explains the role that historical trauma has played in generating the
complex traumatic stress experienced by these children, but it also
highlights ongoing efforts to integrate cultural practices and
traditional healing into therapeutic interventions for American Indian
and Alaska Native families struggling with addiction and child
maltreatment issues. OVC will debut the video at its upcoming Indian
Nations Conference in December and is confident that it will become an
invaluable tool in helping child welfare and mental health
professionals, among others, who are seeking information on innovative
techniques to improve outcomes for drug-endangered children in American
Indian and Alaska Native communities.
OVC funds the Children's Justice Act (CJA) Partnerships for Indian
Communities Grant Program. OVC dedicated $8.1 million to support tribes
in developing, establishing and operating programs to improve the
investigation, prosecution and handling of child abuse cases,
particularly cases of child sexual abuse, in a manner that limits
additional trauma to child victims. The funding further supports the
development and implementation of comprehensive programs for abused
children, and procedures to address child abuse cases in tribal courts
and child protection service systems. OVC is also working with the
Flandreau Indian School, a Bureau of Indian Education boarding school
in South Dakota, to provide specialized mental health services to
students identified as victims. OVC is providing $1.5 million to
support this demonstration project with the goal of establishing a
culturally appropriate, trauma-informed system of care for students
with long-term exposure to violence, trauma, and victimization.
Closing Statement
Mr. Chairman, OJJDP strives to strengthen the juvenile justice
system's efforts to protect public safety, hold offenders accountable
and provide services that address the needs of youth and their
families. We are committed to working with American Indian and Alaskan
Native communities, and our partner agencies within the Department of
Justice and throughout federal and state governments, to implement
evidence-based approaches to preventing and addressing child trauma. I
appreciate the opportunity to appear before you today, and I am
prepared to respond to any questions you may have.
The Chairman. Thank you very much, Mr. Listenbee
Yvette Roubideaux.
STATEMENT OF HON. YVETTE ROUBIDEAUX, MD, MPH, ACTING DIRECTOR,
INDIAN HEALTH SERVICE
Dr. Roubideaux. Thank you, Mr. Chairman, Vice Chairman
Barrasso, and members of the Committee.
I am Dr. Yvette Roubideaux, Acting Director of the Indian
Health Service. I appreciate the opportunity to testify on
preventing and addressing childhood trauma in Indian Country.
Thank you so much for holding this hearing today on such a
truly important topic. It is a serious problem with multiple
reasons and causes as detailed in the testimony and has a
profound impact on our communities.
The problem of childhood trauma is multigenerational and a
societal problem. It is sweeping in scope and will take a
coordinated, comprehensive, multidimensional, public health
response to change the course for our children and youth.
I appreciate the opportunity discuss with the Committee
what IHS is doing to address the many issues related to
childhood trauma and be a part of the solution for these public
health challenges.
IHS is already and wants to continue to be a partner with
other agencies, stakeholders and tribes in these efforts to
find solutions. My testimony summarizes some of the major
national programs and activities that IHS does for this issue
as a part of our medical and public health response to
childhood trauma.
For the sake of time, I will just summarize by saying that
the IHS' policies, training, programs and partnerships promote
a multifaceted range of activities for the identification,
treatment and prevention of childhood trauma.
However, IHS cannot address these issues alone and it will
take all of us to prevent and reduce childhood trauma. We
welcome your partnership and assistance with this important
issue.
That concludes my remarks. Thank you.
[The prepared statement of Dr. Roubideaux follows:]
Prepared Statement of Hon. Yvette Roubideaux, MD, MPH, Acting Director,
Indian Health Service
Mr. Chairman and Members of the Committee:
Good afternoon, I am Dr. Yvette Roubideaux, Acting Director of the
Indian Health Service (IHS). Today, I appreciate the opportunity to
testify on preventing and addressing childhood trauma in Indian
Country.
Background
As you know, the IHS plays a unique role in the U.S. Department of
Health and Human Services (HHS) to meet the federal trust
responsibility to provide health care to American Indian and Alaska
Native (AI/AN) people. The IHS provides comprehensive health service
delivery to 2.1 million American Indians and Alaska Natives through a
system of IHS, Tribal, and urban Indian operated facilities and
programs based on treaties, judicial determinations, and Acts of
Congress. The mission of the agency is to raise the physical, mental,
social, and spiritual health of AI/AN people to the highest level, in
partnership with the population we serve. The agency aims to assure
that comprehensive, culturally acceptable personal and public health
services are available and accessible to the service population. Our
foundation is to promote healthy AI/AN people, communities, and
cultures, and to honor the inherent sovereign rights of Tribes.
Two major pieces of legislation are at the core of the Federal
Government's responsibility for meeting the health needs of American
Indians and Alaska Natives: The Snyder Act of 1921, P.L. 67-85, and the
Indian Health Care Improvement Act (IHCIA), P.L. 94-437, as amended.
The Snyder Act authorized appropriations for ``the relief of distress
and conservation of health'' of American Indians and Alaska Natives.
The IHCIA was enacted ``to implement the federal responsibility for the
care of the Indian people by improving the services and facilities of
federal Indian health programs and encouraging maximum participation of
Indians in such programs.'' Like the Snyder Act, the IHCIA provides the
authority for the provision of programs, services, functions and
activities to address the health needs of American Indians and Alaska
Natives. The IHCIA includes authorities for the recruitment and
retention of health professionals serving Indian communities, health
services for AI/AN people, and the construction, replacement, and
repair of healthcare facilities, among other authorities.
The IHS, in partnership with Tribes and urban Indian health
programs, provides essential medical and mental health services in over
600 hospitals, clinics, and health stations. These services include
medical and surgical inpatient care, emergency care, ambulatory care,
mental health and substance abuse treatment and prevention, and medical
support services such as laboratory, pharmacy, nutrition, diagnostic
imaging, medical records, and physical therapy. Other services include
public and community health programs such as diabetes; maternal and
child health; communicable diseases such as influenza, HIV/AIDS,
tuberculosis, and hepatitis; suicide prevention; substance abuse
prevention; women's and elders' health; domestic violence prevention
and treatment; and regional trauma/emergency medical delivery systems.
The level of services provided in each community varies based on
available resources. In addition, over half of the IHS budget is
managed by Tribes under P.L. 93-638, the Indian Self Determination and
Educational Assistance Act, and many of the public, community and
behavioral health programs are managed by Tribes even when the hospital
or clinic is still under management by the IHS.
Childhood Trauma in AI/AN Children
According to the National Child Abuse and Neglect Data System, an
estimated 686,000 children were exposed to incidents of child abuse and
neglect in 2012. These data translate to a rate of 9.2 occurrences of
child abuse and neglect for every 1,000 children per year. \1\ While
these data are not unique to AI/AN children, childhood trauma is
disproportionately experienced by AI/AN children. The reasons are
multifactorial and related to the high incidence of alcohol and drug
abuse, mental health disorders, suicide, violence, and behaviorally-
related chronic diseases among AI/AN people. Recurrent physical,
emotional, and sexual abuse, as well as emotional and physical neglect
leads to childhood trauma impacting the mental health and wellbeing of
children. Other contributing factors of childhood trauma include
household members who may have a substance abuse disorder, chronic
depression, or other mental health diagnoses, family members who may be
incarcerated, experience suicidal ideation, domestic violence in the
household, and parental loss. Each of these serious behavioral health
related issues have a profound impact on childhood trauma, the health
of individuals, family, and community wellbeing.
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\1\ U.S. Department of Health & Human Services. Administration for
Children and Families. (2012). Child Maltreatment 2012. Available at
http://www.acf.hss.gov/programs/cb/stats_research/index.htm#can
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Once again, another school shooting has shaken us to our core as
one of the Nation's most serious tragedies. The heartbreak facing the
Marysville, Washington, community and Tulalip Tribe offers another
opportunity for a collective effort to reduce the chances of similar
future tragedies. There are no easy solutions and no single agency or
single approach that will address the violence and many other problems
impacting the mental health of our children and youth. The problem of
childhood trauma is a multigenerational and societal problem. It is
sweeping in scope and will take a coordinated, comprehensive, multi-
dimensional public health response to change the course for our
children and youth. Today, I appreciate the opportunity to discuss what
the IHS is doing to address the many issues that relate to childhood
trauma and to be part of the solution for these public health
challenges. IHS is already, and wants to continue to be, a partner with
other agencies, stakeholders and Tribes in these efforts to find
solutions.
IHS Medical and Public Health Response to Childhood Trauma
The overall structure and types of services provided by IHS, Tribal
and urban Indian health programs were described above. The funding IHS
receives to provide primary care and behavioral health services is
through the Hospitals and Health Clinics, Mental Health and Alcohol and
Substance Abuse budgets, of which over 50 percent of funds are
transferred under P.L. 93-638 contracts or compacts to Tribal
governments or Tribal organizations that design and manage the delivery
of health programs in their communities. In addition, there are 34
urban Indian health programs serving approximately 600,000 AI/AN
people, including children with varying levels of services.
In Fiscal Year (FY) 2013, IHS per capita spending estimates were
$47 per person for mental health services and $117 per person for
alcohol and substance abuse services. The average public and private
expenditure among school-age American children from 2009-2011 was
$2,192 for mental health services. \2\ While the IHS overall spending
estimate on mental health services is not directly comparable for the
amount spent per AI/AN child due to the nature of how services are
accessed through our health system, it is a glimpse into the
complexities faced by Tribes in providing comprehensive services for
children and families. I would like to provide an overview of some of
our major national programs and activities that are part of the IHS
medical and public health response to childhood trauma.
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\2\ U.S. Department of Health & Human Services., (2014).
Expenditures for Treatment of Mental Health Disorders among Children,
Ages 5-17, 2009-2011: Estimates for U.S. Civilian Noninstitutionalized
Population. Published by Agency for Healthcare Research and Quality.
Available at: http://meps.ahrq.gov/mepsweb/data_files/publications/
st440/stat440.shtml
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National Policy
I spoke in my introduction about the dire statistics on child abuse
and neglect and its huge impact on AI/AN children and youth. IHS works
to positively influence the outcomes for children and youth who are
victims of child maltreatment through development of policies,
objectives, procedures, and responsibilities concerning the detection,
management, prevention, and evaluation of child abuse and neglect. The
IHS recently recognized the need for a more comprehensive, standalone
policy, and the IHS is drafting a comprehensive national Child
Maltreatment policy to ensure children who are abused or neglected
receive comprehensive intervention and treatment services when they
enter our health system, as well as outlines the health care
responsibilities in providing a coordinated multidisciplinary response.
This policy will help improve and enhance our overall response at IHS
facilities.
Training
The IHS offers a comprehensive training program to meet the needs
of our workforce as it relates to addressing childhood trauma. Specific
for child abuse, IHS provides training related to the identification,
collection, and preservation of medical forensic evidence obtained
during the treatment of child sexual abuse. Monthly webinars ensure the
Indian health system receives the continuing education needed to
maintain competencies in the treatment, prevention, and coordination of
services for child maltreatment. For current and pressing behavioral
health issues related to childhood trauma, the IHS provides virtual
training seminars and consultation sessions on topics including child
mental health, childhood trauma, suicide, historical trauma, Fetal
Alcohol Spectrum Disorders, and school violence, among others.
Youth Regional Treatment Centers
To help youth battling substance abuse, IHS administers ten Youth
Regional Treatment Centers (YRTCs) that provide inpatient treatment for
substance abuse and co-occurring mental health disorders among AI/AN
youth. The YRTCs provide a range of clinical services rooted in
culturally relevant, holistic models of care including group,
individual, and family psychotherapy, life skills development,
medication management, aftercare relapse prevention, and post-treatment
follow up services. YRTCs also provide education, culture-based
prevention activities, and evidence- and practice-based models of
treatment to assist youth overcome their challenges and become healthy,
strong, and resilient community members.
Recently, the Jack Brown Center, an IHS funded YRTC that is located
in Tahlequah, Oklahoma, completed construction on a new facility that
will increase Jack Brown's capacity from 20 to 36 inpatient beds.
Additionally, Congress authorized two YRTCs to be built in the IHS
California Area. The Southern California facility is expected to open
in FY 2015, and staffing costs were included in the FY 2015 President's
Budget. The FY 2015 Budget also included construction costs for the
Northern California YRTC.
Community Health Representatives
The IHS Community Health Representative, or CHR, program is
community-based program with a special focus on advocacy, health
promotion, and disease prevention. In 2013, the CHR program partnered
with Johns Hopkins University to implement Family Spirit, an evidence-
based and culturally tailored in-home parent training and support
program. Parents gain knowledge and skills to achieve optimum
development for their preschool aged children across the domains of
physical, cognitive, social-emotional, language learning, and self-
help. The program is currently the largest, most rigorous, and only
evidence-based home visiting program ever designed specifically for
American Indian families. In 2013, IHS provided funding to further
replicate the program in three American Indian communities.
Methamphetamine and Suicide Prevention Initiative
The IHS Methamphetamine and Suicide Prevention Initiative, or MSPI,
is one of the most significant efforts at the core of the IHS' response
to methamphetamine abuse and suicide in AI/AN communities. The MSPI's
purpose is to promote the use and development of evidence-based and
practice-based models that represent culturally-appropriate prevention
and treatment approaches to methamphetamine abuse and suicide
prevention from a community-driven context. Of the 130 IHS, Tribal, and
urban Indian health projects supported across the country through the
MSPI, over 80 percent of projects provide prevention and treatment
services to youth. For example, one Tribal project increased access to
services by funding school based mental health professionals at
community schools. Youth now have immediate access to mental health
providers in a familiar environment. These professionals are
responsible for providing on-going mental health services to youth, as
well as providing educational groups related to suicide, grief, and
loss. School officials have witnessed the impact of the school-based
health services and report youth are more likely to talk about suicide
and reach out for help.
Throughout the 5 years of the MSPI, projects have significantly
raised awareness through diverse and innovative programming. From 2009-
2013, the MSPI resulted in more than 7,500 individuals entering
treatment for methamphetamine abuse, over 15,000 tele-health substance
abuse and mental health encounters, over 10,000 professionals and
community members trained in suicide prevention and crisis response,
and over 400,000 encounters with youth were provided as part of
evidence-based and practice-based intervention and prevention services.
Community Awareness
To raise youth awareness on the issues of substance abuse and
suicide, the IHS partnered with the Northwest Portland Area Indian
Health Board to develop media campaigns. Using focus groups, youth
developed the ``I Strengthen My Nation'' and ``Community is the
Healer'' media campaigns, which empower Native youth to resist drugs
and alcohol, motivates parents to talk openly to their children about
drug and alcohol use, and raises awareness about the issue of suicide.
Domestic Violence Prevention Initiative
To prevent domestic and sexual violence, as well as family
violence, the IHS administers the Domestic Violence Prevention
Initiative, or DVPI. Through DVPI, 65 IHS, Tribal, and urban Indian
health projects provide outreach, victim advocacy, intervention, policy
development, and community response teams. From 2010-2012, the DVPI
resulted in over 28,000 direct service encounters including crisis
intervention, victim advocacy, case management, and counseling
services; over 36,000 referrals for domestic violence services,
culturally-based services, and clinical behavioral health services;
with 487 forensic evidence collection kits submitted to federal, state,
and Tribal law enforcement.
Drug and Alcohol Exposure during Pregnancy
To identify women who are using alcohol and drugs during pregnancy,
IHS healthcare facilities conduct screening during routine women's
health and prenatal encounters. In FY 2013, 65.7 percent of all AI/AN
females ages 15 to 44 were screened for alcohol use. In one IHS service
unit, approximately 54 percent of women tested positive for drug use
while pregnant and 52 percent of the infants born tested positive for
drugs. To combat this problem, IHS has drafted policies and coordinated
efforts for a comprehensive and multidisciplinary response to provide
services to mothers and families including prenatal services,
treatment, and home visiting programs to promote healthy lifestyles.
Fetal Alcohol Spectrum Disorder
For the babies born with Fetal Alcohol Spectrum Disorders, or FASD,
which is an umbrella term describing the range of effects that can
occur in an individual whose mother drank alcohol during pregnancy, IHS
administers the Fetal Alcohol and Drug Unit (Unit), located within the
University of Washington's Alcohol and Drug Abuse Institute. The Unit
provides FASD information and strategies for prevention and
intervention to AI/AN communities. Since 2012, over 300 high-risk,
substance-abusing pregnant and parenting women and their families have
received evaluation, diagnosis, and referral services through the Unit.
Additionally, the Unit has provided training and technical assistance
to over 4,400 healthcare providers and AI/AN community members on FASD
prevention and intervention topics.
IHS Partnerships
The IHS has devoted considerable effort to develop and share
effective programs throughout the Indian health system. Strategies to
address public safety and justice issues that impact childhood trauma
include collaborations and partnerships between IHS, Substance Abuse
and Mental Health Services Administration, Department of Justice (DOJ),
and Department of Interior (DOI) through three Memoranda of
Understanding, established by the Tribal Law and Order Act, Indian
Health Care Improvement Act, and Individuals with Disabilities
Education Act. These interagency coordination efforts work to ensure
Federal agencies are comprehensively addressing the serious problems
that have a significant impact on childhood trauma, such as alcohol,
substance abuse, mental illness.
The IHS is working with other federal officials from DOJ and DOI as
part of the Defending Childhood Initiative as a member of the American
Indian/Alaska Native Children Exposed to Violence Federal workgroup.
This partnership seeks to take immediate steps to improve the Federal
response to AI/AN children exposed to violence. The role of IHS in this
group is to ensure services are comprehensive and coordinated so that
every child has access to medical and counseling appointments in a
timely manner and on a routine basis.
The IHS partnership with the American Academy of Pediatrics'
Committee on Native American Child Health (CONACH) works to develop
policies and programs to improve the health of AI/AN children. CONACH
members are committed to increasing awareness of the major health
problems facing Native American children and monitoring legislation
affecting AI/AN child health. CONACH conducts pediatric consultation
visits to IHS and Tribal healthcare facilities, makes recommendations
to improve services, and works to strengthen ties with Tribes
throughout the United States.
Summary
In summary, IHS policies, training, programs, and partnerships
promote a multifaceted range of activities for identification,
treatment and prevention of childhood trauma. However, IHS cannot
address this issue alone, and it is imperative to continue to build a
wide safety net of Federal, non-Federal and Tribal resources for AI/AN
children and families to help to further activities at the national,
Tribal, state, and local levels. No one individual, community, or
agency can do this alone. It will take all of us to prevent and reduce
childhood trauma and we welcome your partnership and assistance with
this important issue.
This concludes my remarks and I welcome any questions that you may
have. Thank you.
The Chairman. Thank you, Dr. Roubideaux.
Kana.
STATEMENT OF KANA ENOMOTO, PRINCIPAL DEPUTY
ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION
Ms. Enomoto. Good afternoon, Chairman Tester, Vice Chairman
Barrasso and members of the Committee.
Thank you for inviting the Substance Abuse and Mental
Health Services Administration to testify here today. I am
pleased to be here with my colleagues from IHS, DOJ and from
the field.
I am particularly pleased to be here this morning, Senator
Heitkamp, because I too heard from the faces of the statistics.
SAMHSA's Native Youth Conference was convened and we had a
Federal listening panel.
We heard loudly and clearly from Native youth from across
the country that they want us to address childhood trauma. They
want us to address the violence and the substance abuse in
their communities and they want to be our partners in finding
ways to heal and help their communities find a path to
recovery, to hope and wellness, and doing that in a culturally,
developmentally appropriate way.
SAMHSA has many programs in its portfolio that address this
issue. You also have that in my written testimony. I want to
highlight for you one particular program; The Tribal Behavioral
Health Grant Program.
The President has requested for several years in a row
funding to provide stable, predictable funding to all tribes to
do substance abuse prevention, suicide prevention and mental
health promotion in ways that fit their needs, that they can
determine the best practices to use in that space.
Just this last year, in FY14, Congress started us off with
$5 million and we were able to give grants to 20 tribes with
some of the highest rates of suicide. As you can imagine, that
is not enough.
We need to do more and look forward to doing more. We have
invested for many years in the National Child Traumatic Stress
Initiative which Dr. van den Pol will tell you more about. That
is a space where we are also trying to promote effective
clinical interventions for child trauma. We have funded the
center at the University of Montana where we can bring together
effective clinical interventions with cultural adaptations and
traditional healing practices.
We hope to do much more of that and partner with our
colleagues across the Federal Government and Indian Country.
We thank you very much for having this hearing.
[The prepared statement of Ms. Enomoto follows:]
Prepared Statement of Kana Enomoto, Principal Deputy Administrator,
Substance Abuse and Mental Health Services Administration
Chairman Tester, Ranking Member Barrasso, and members of the Senate
Committee on Indian Affairs, thank you for inviting me to testify at
this important hearing on protecting our children's mental health. I am
pleased to testify along with my colleagues from the Indian Health
Service (IHS) and the Department of Justice, and inform the Committee
of the Administration's efforts to prevent and address childhood trauma
in Indian Country. I am particularly pleased to be here today for
several reasons. First, I began my career at the Substance Abuse and
Mental Health Services Administration (SAMHSA) over fourteen years ago
working on childhood trauma programs and have had the opportunity to
see the agency's programs evolve and expand over the years. In
addition, just this past summer I accompanied Administrator Hyde to
Indian Country where we visited tribes and Alaska Native villages in
three of the states represented by members of this Committee. Shortly
thereafter, SAMHSA established the agency's Office of Tribal Affairs
and Policy (OTAP), which serves as SAMHSA's primary point of contact
for tribal governments, tribal organizations, Federal departments and
agencies' tribal affairs efforts, and other governments and agencies on
behavioral health issues facing American Indian and Alaska Native (AI/
AN) populations in the United States. Finally, as I speak, SAMHSA is
wrapping up its 2014 Native Youth Conference, which has focused on
addressing behavioral health issues facing AI/AN youth.
SAMHSA
As you are aware, SAMHSA's mission is to reduce the impact of
substance abuse and mental illness on America's communities. SAMHSA
envisions a Nation that acts on the knowledge that:
Behavioral health is essential for health;
Prevention works;
Treatment is effective; and
People recover from mental and substance use disorders.
In order to achieve this mission, SAMHSA has identified six
Strategic Initiatives to focus the Agency's work on improving lives and
capitalizing on emerging opportunities. SAMHSA's top Strategic
Initiatives are: Prevention of Substance Abuse and Mental Illness;
Health Care and Health Systems Integration; Trauma and Justice;
Recovery Support; Health Information Technology; and Workforce
Development.
SAMHSA's Trauma and Justice Strategic Initiative provides a
comprehensive public health approach to addressing trauma and
establishing a trauma-informed approach in health, behavioral health,
human services, and related systems, with the intent to reduce both the
observable and less visible harmful effects of trauma and violence on
children and youth, adults, families, and communities. Recent
activities of the strategic initiative include hosting a Tribal
Juvenile Justice Policy Academy and releasing SAMHSA's paper entitled
``Concept of Trauma and Guidance for a Trauma-Informed Approach.''
SAMHSA has participated in the Department of Justice's Task Force on
American Indian and Alaska Native Children Exposed to Violence and will
work with our partners at the Office of Juvenile Justice and
Delinquency Prevention to address the recommendations of the report.
The Concept of Trauma and Guidance for a Trauma-Informed Approach
publication was released in July of this year. SAMHSA intends this
framework to be relevant to its Federal partners and their state,
tribal and local system counterparts and applicable to practitioners,
researchers, and trauma survivors, families and communities. The
framework is anchored in SAMHSA's concept of trauma which is that
``individual trauma results from an event, series of events, or set of
circumstances that is experienced by an individual as physically or
emotionally harmful or life threatening and that has lasting adverse
effects on the individual's functioning, and mental, physical, social,
emotional or spiritual well-being.'' \1\ The focus on experience
highlights the fact that not every child will experience the same
events as traumatic. While the immediate focus might be on a recent
event, the individual's reaction to that event may be affected by
earlier experiences. As an example: A child bullied in school that
comes for treatment or support may have experienced neglect or abuse at
home, lived in multiple foster care settings, and witnessed the impact
of community violence. That child may experience the bullying event
very differently from a child who has not been exposed to prior
traumatic events or circumstances.
---------------------------------------------------------------------------
\1\ Substance Abuse and Mental Health Services Administration.
SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach.
HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2014.
---------------------------------------------------------------------------
Prevalence of Behavioral Health Conditions and Treatment
According to SAMHSA's 2012 National Survey on Drug Use and Health
(NSDUH), the statistics related to behavioral health conditions among
the AI/populations are very troubling.
Mental Health
5.2 percent of American Indian/Alaska Native youth had a
major depressive episode (MDE) and 2.6 percent had an MDE with
severe impairment.
NSDUH also found that in 2012, 11 percent of AI/AN youth had
specialty mental health services during the past year with
services provided in a range of settings from education and
juvenile justice settings to general and specialty health
settings.
Substance Misuse and Abuse
The rate of substance dependence or abuse among people aged
12 and up was higher among the AI/AN population (21.8 percent)
than among other groups.
AI/AN individuals have the highest rate of binge alcohol use
(30.2 percent) compared with other groups.
American Indians and Alaska Natives are also more likely
than other groups in the United States to die from drug-induced
deaths, according to a 2013 Centers for Disease Control and
Prevention (CDC) report on U.S. health disparities and
inequities.
Suicidal Thoughts, Attempts and Completions
Based on data from SAMHSA and CDC, we also know that AI/AN youth
are disproportionally impacted by suicide.
In 2011, American Indian and Alaska Native high school
students reported rates of suicide attempts nearly twice that
of the general population of U.S. high school students (14.7
percent vs. 7.8 percent).
In 2012, the suicide rate among American Indians and Alaska
Natives ages 10 to 24 years was 14.2 per 100,000, significantly
higher than the suicide rate for people of the same age with
the next highest rate (white 8.66) and almost three times the
suicide rate for Asian/Pacific Islanders (5.51) and blacks
(5.27).
In 2012, 5.9 percent of American Indians and Alaska Natives
ages 18 and up had serious thoughts of suicide in the past
year. This is higher than any other single racial or ethnic
group.
Trauma
Based on SAMHSA's definition of trauma, the agency is in the
process of developing and implementing trauma measures for population
surveillance, client level data, facilities surveys, and quality
measures.
Improving Practice
SAMHSA, as the Federal agency that leads public health efforts to
advance the behavioral health of the nation, has several roles. I just
spoke about the ways in which SAMHSA provides leadership and voice and
supports the behavioral health field with critical data from national
surveys and surveillance. SAMHSA also has a vital role in collecting
best practices and developing expertise around prevention and treatment
for people with mental illness and substance use disorders. SAMHSA's
staff includes subject matter experts that provide technical assistance
and training to individuals, organizations, states, tribes, and others
every day. SAMHSA also supports a number of technical assistance and
training centers that are focused on children's mental health and
addressing and preventing trauma.
The SAMHSA Tribal Training and Technical Assistance (TTA) Center
uses a culturally relevant, evidence-based, holistic approach to
support Native communities in their self-determination efforts through
infrastructure development and capacity building, as well as program
planning and implementation. It provides training and technical
assistance on mental and/or substance use disorders, suicide
prevention, and mental health promotion. It also offers training and
technical assistance, ranging from broad to focused and intense to
federally recognized tribes, SAMHSA tribal grantees, and tribal
organizations serving Indian Country.
The National Center for Child Traumatic Stress (NCCTS) facilitates
collaborative activity, oversees resource development, and coordinates
national training and education for the National Child Traumatic Stress
Network. Housed jointly at the UCLA Neuropsychiatric Institute and the
Duke University Medical Center, the NCCTS works to increase access to
services and raise the standard of care for traumatized children and
their families.
The Suicide Prevention Resource Center (SPRC) also has a special
focus on American Indians and Alaska Natives. SPRC provides technical
assistance, training, and materials to increase the knowledge and
expertise of suicide prevention practitioners and other professionals
serving people at risk for suicide.
SAMHSA has also published ``To Live To See the Great Day That
Dawns: Preventing Suicide by American Indian and Alaska Native Youth
and Young Adults'' which lays the groundwork for community-based
suicide prevention and mental health promotion plans for American
Indian and Alaska Native youth and young adults.
Public Awareness and Support
Creating public awareness of children's mental health issues and
targeting campaigns to prevent and address childhood trauma is a key
role that SAMHSA plays in reducing the impact of mental illness and
substance abuse in America's communities. For example, in 2006 the
SAMHSA-funded National Suicide Prevention Lifeline created a specific
set of outreach materials for AI/AN teen suicide prevention public
awareness campaign. The poster utilized in the campaign depicts an
American Indian male who appears to have lost hope. But, the image
emphasizes that there is help, and with help comes hope and urges those
who are thinking about suicide to call the Lifeline. Posters to promote
AI/AN use of the Lifeline are available for free from SAMHSA's website
and can be downloaded and printed or ordered from SAMHSA's online
store. SAMHSA encourages tribes and tribal organization to place the
posters in a wide range of settings to ensure AI/AN individuals are
aware of the Lifeline.
As part of SAMHSA's highly successful ``Talk. They Hear You.''
underage drinking prevention campaign, a promotion video was recently
recorded with Rod Robinson, the former Director of SAMHSA's Office of
Indian Alcohol and Substance Abuse. In the video Mr. Robinson discusses
materials developed to help prevent and reduce underage drinking in
American Indian communities and he responds to questions such as why
underage drinking is an important concern for American Indian
populations. He also communicates ways in which the new ``Talk. They
Hear You.'' materials will help parents and adult caregivers address
underage drinking within tribal communities. The video is available on
SAMHSA's You Tube channel.
Strategic Grant Making
National Child Traumatic Stress Initiative
Established in 2000, the purpose of the National Child Traumatic
Stress Initiative (NCTSI) is to improve behavioral health treatment,
services, and interventions for children and adolescents exposed to
traumatic events. It has done so through the National Child Traumatic
Stress Network (NCSTN), a national network of centers with expertise in
child trauma. The goals of the NCTSN are to develop highly effective
clinical and service interventions for child trauma, expand
availability and accessibility of effective trauma-informed
interventions, and promote better understanding of issues relevant to
developing and providing effective interventions for children,
adolescents, and families exposed to traumatic events. To date, the
NCTSI has funded over 200 grants across the country.
The National Native Children's Trauma Center (NNCTC) at the
University of Montana works in collaboration with IHS and other
providers in tribal communities across the country to utilize evidence-
based, culturally appropriate, trauma-informed interventions for AI/AN
children, youth, and families who experience disproportionate violence,
grief, and/or poverty; and childhood, historical, and/or
intergenerational trauma. The NNCTC has delivered education and
services in a broad range of locations and settings including the Fort
Peck, Rocky Boy, Northern Cheyenne, Crow, Pine Ridge, White Earth,
Leech Lake, Blackfeet and Flathead Reservations; Cracking Ice Lake,
Pine Point, and Waubun, Minnesota; and Bethel, Anchorage, Emmonak, and
Napis, Alaska just to name a few. NNCTC provides trainings and
consultation in trauma-focused interventions such as Trauma-Focused
Cognitive Behavioral Therapy; Attachment, Self-Regulation and
Competency Clinical Services; Family Engagement through the Joining
Process: Welcome, Honor, and Connect; trauma awareness, implications of
the Adverse Childhood Experiences study; and the Students, Trauma, and
Resiliency curriculum. The NNCTC has trained social workers, school
counselors, nurses, and child protection workers. From April to June
2014, the NNCTC trained 1,180 individuals provided services at 46 sites
and collaborated with 58 other organizations.
Other tribal focused grantees include the Native American Health
Center (NAH) in Oakland, CA, which is using grant resources to further
bridge the gap between western and AI/AN models of addressing trauma.
In the past year, using evidence-based and trauma-focused
interventions, NAH therapists have been working with three school age
siblings who experienced multiple traumas, including the sudden death
of their mother. NAH therapists integrated culturally adapted evidence-
based trauma interventions developed and disseminated by the National
Child Traumatic Stress Network, with traditional Native healing
practices including participation in Cultural Ceremonies. For example,
at the start of their treatment, one of the children was at risk for
placement in a hospital or residential care setting, and the other two
had significant behavior and emotional problems. At present all three
are together in the care of their mother's sister and nearing a
successful end to their treatment. As a result of the multi-focused
trauma treatment and the interventions of therapists, children and
families are receiving effective and culturally sensitive healing
services.
Tribal Behavioral Health Grants
For several years, the President's Budget for SAMHSA had requested
funding to address the high incidence of substance abuse and suicide in
AI/AN youth and young adult populations. In Fiscal Year 2014, Congress
appropriated for the first time $5 million to begin such a program,
Tribal Behavioral Health (Native Connections). SAMHSA recently awarded
20 Tribal Behavioral Health grants of $200,000 to tribes or tribal
organizations with high rates of suicide to develop and implement a
plan that addresses suicide and substance abuse (including alcohol) and
is designed to promote mental health among tribal youth. Grantees such
as the Selawik Village Council in Alaska, the Turtle Mountain Band of
Chippewa Tribe in North Dakota, and the Pueblo of Nambe in New Mexico,
indicated in their applications how they will incorporate evidence-
based, culture-based, and practice-based strategies for tribal youth.
Grantees are required to work across tribal suicide prevention, mental
health, substance abuse prevention, and substance abuse treatment
programs to build positive behavioral health among youth. Using real-
time surveillance data of suicide deaths and attempts, grantees will
create or enhance effective systems of follow up for those identified
at risk of suicide and/or substance abuse or mental health issues that
could lead to suicide. With a focus on tribal traditions, interagency
collaboration, early identification, community healing, and preventing
future deaths by suicide, grantees will connect appropriate cultural
practices, intervention services, care, and information with families,
friends, schools, educational institutions, correctional systems,
substance abuse programs, mental health programs, foster care systems,
and other support organizations for tribal youth. Attention to the
families and friends of tribal community members who recently died by
suicide is encouraged as well. In addition, technical assistance will
be provided to grantees through SAMHSA's Tribal Technical Assistance
Center to support their ability to achieve their goals.
GLS Youth Suicide Prevention
The Garrett Lee Smith (GLS) Memorial Act authorizes SAMHSA to
manage two significant youth suicide prevention programs and one
resource center. The GLS State/Tribal Youth Suicide Prevention and
Early Intervention grant program currently supports a total of 68
grantees which includes 29 tribes or tribal organizations in developing
and implementing youth suicide prevention and early intervention
strategies involving public-private collaborations among youth serving
institutions. Recently announced tribal grantees include Native
Americans for Community Action in Arizona, Confederated Salish and
Kootenai Tribes in Montana, and the Yellowhawk Tribal Health Center in
Oregon. The GLS Campus Suicide Prevention program currently provides
funding to 82 institutions of higher education, inclusive of tribal
colleges and universities. In a cross site evaluation of the GLS State/
Tribal grant program, it was found that counties that had implemented
grant supported youth suicide prevention activities had lower youth
suicide rates than matched counties that had not implemented such
activities in the year following those activities.
Project LAUNCH (Linking Actions for Unmet Needs in Children's Health)
Project LAUNCH is a grant program that invests in ensuring healthy
physical, social, emotional, cognitive, and behavioral development of
young children. This investment forms the foundation for later success
in school and life and serves to protect against negative outcomes such
as school dropout, drug and alcohol abuse, delinquency, and other
physical, social, and emotional problems. Project LAUNCH grantees
implement, monitor, and evaluate evidence-based prevention and
promotion practices in partnership with a wide variety of community
organizations and stakeholders. Project LAUNCH services are focused on
five core strategies for promoting the social and emotional wellbeing
of young children and their families: (1) increased developmental
screening in a wide range of early childhood settings; (2) enhanced
home visiting (with a focus on social/emotional wellbeing); (3) mental
health consultation in early care and education settings; (4)
integration of behavioral health into primary care; and (5) family
strengthening/parent support. Each state/tribe and community's Project
LAUNCH Council on Young Child Wellness monitors infrastructure
development, implementation of evidence-based practices, and
sustainability of successful practices through policy, planning, data,
and funding decisions that improve services and outcomes for young
children and their families.
Project LAUNCH has funded a total of 10 Tribal grantees. The Red
Cliff Band of Lake Superior Chippewa completed a Project LAUNCH grant
and tribal members have noted that the grant continues to serve as one
of the powerful transformative mechanisms for the Red Cliff community.
For example, during the grant period one leader noted that ``I think
the most important thing that LAUNCH is helping us do is looking at the
difficult things the families have to juggle, making us take a step
back and take a look from the family's point of view. And say, `Okay,
if I was in that position, what would I need to help me?' or better
yet, asking the family, `What do you need for help?'''
Children's Mental Health Initiative (CMHI)
The CMHI supports the development of comprehensive, community-based
systems of care for children and youth with serious emotional disorders
(SED) and their families. A system of care (SOC) is a strategic
approach to the delivery of services and supports that incorporate
family-driven, youth-guided, strength-based, and culturally and
linguistically competent care in order to meet the physical,
intellectual, emotional, cultural, and social needs of children and
youth. These guiding principles also call for a broad array of
effective services, individualized care, and coordination across child
and youth-serving systems (e.g. juvenile justice, child welfare,
education, primary care, and substance abuse) and have become standards
for care throughout much of the nation. Recently announced CMHI
grantees include Rocky Boy Health Board in Montana, the Santee Sioux
Nation in North Dakota, and Lummi Nation in Washington.
National program evaluation data reported annually to Congress
indicates that CMHI systems of care are successful, resulting in many
favorable outcomes for children, youth, and their families, including:
Sustained mental health disorder improvements for
participating children and;
Improvements in school attendance and achievement;
Reductions in suicide-related behaviors;
Decreases in the use of inpatient care and reduced costs due
to fewer days in residential settings; and
Significant reductions in contacts with law enforcement.
Circles of Care Grant Program
The Circles of Care program is the longest running SAMHSA grant
program specifically designed for AI/AN communities. The program began
in 1998 as a result of discussion and consultation with tribes and
American Indian behavioral health professionals. To date, SAMHSA has
awarded a total of $49 million in Circles of Care grants to 49 AI/AN
communities. These communities have mobilized to develop the tools and
resources necessary to build their own culturally competent systems of
care model for children's mental health. Thus, many Circles of Care
grantees go on to receive larger CMHI grants
In FY14, SAMHSA funded 11 tribes and tribal organization as part of
a new cohort of Circles of Care grantees. Among the grantees include
the Osage Tribe of Indians in Oklahoma, the Makah Tribe in Washington,
and the Red Cliff Band of Lake Superior Chippewa in Wisconsin.
Conclusion
Thank you again for this opportunity to discuss children's mental
health as it relates to preventing and addressing childhood trauma in
Indian Country. I hope you can see that this issue is a major priority
for SAMHSA and recent activities such as the establishment of our OTAP,
release of the trauma concept paper, and hosting this week's Native
Youth Conference underscore our dedication. I would now be pleased to
answer any questions that you may have.
The Chairman. Kana, thank you for your testimony.
Rick?
STATEMENT OF RICK VAN DEN POL, Ph.D., DIRECTOR AND PRINCIPAL
INVESTIGATOR, INSTITUTE OF EDUCATIONAL RESEARCH AND SERVICE,
THE UNIVERSITY OF MONTANA NATIONAL NATIVE CHILDREN'S TRAUMA
CENTER
Dr. Van Den Pol. Thank you for the invitation.
My name is Rick van den Pol. I serve as Principal
Investigator at the National Native Children's Trauma Center at
the University of Montana.
I have been a professor at the University of Montana
tenured in psychology and education for 33 years. I have worked
with children who have trauma for 33 years but only about half
the time did I know what trauma was.
Only about half the time was I able to provide trauma-
informed, effective services. This is a very young field and
the science is very young. I cannot give you an authentic
perspective or an authentic Native perspective on childhood
trauma but as principal investigator, I can share with you some
findings from our work in the National Native Children's Trauma
Center.
In my written testimony, I have five exhibits. The first is
a chapter written for pediatricians about the impact of trauma
on the developing child and the developing brain. A very
important component of that message is missing from the
national dialogue about ACE's, Adverse Childhood Experiences.
The missing component is the treatability of childhood
trauma. We absolutely want to invest in long term prevention. I
am reminded of a statement sometimes attributed to Chief Joseph
that we need to consider the impacts of our actions on the next
seven generations. But, the present Congress needs to have some
solutions it can implement more quickly than that.
The second exhibit is a handout from the National Child
Traumatic Stress Network, the network created by the National
Child Traumatic Stress Initiative of SAMHSA.
The handout speaks to the treatability of trauma, the
newness of the science and the importance of training
clinicians who are currently practicing on an in-service basis
and new clinicians as they come through our graduate and
medical schools.
The third finding I share with you is research performed by
Dr. Mary Kaas and colleagues, not associated with our center.
They believe that the prevalence of childhood trauma in Indian
Country is probably about twice as bad as the statistic you
cited, Mr. Chairman.
According to them, using the ACE 4 point scale, about five
times as many individuals in their sample of Native Americans
tested at 4 ACE points. In the original fluidity sample
published by the Centers for Disease Control, it was 20 percent
of that rate and there were also symptoms of trauma present.
The fourth exhibit I offered is work done by one of my
colleagues, Dr. Aaron Morsette, who was then a graduate student
working at our center. Aaron tested a trauma treatment in three
different reservation schools in the northern plains and found
very positive results.
Native students, who qualified, who presented with trauma,
on average, two-thirds showed significant reductions after ten
hours of participation with a group of peers and more than half
showed measurable reductions in symptoms of depression.
Dr. Morsette, as we all were, has been puzzled by the
prevalence of trauma in Indian people. His dissertation, yet
unpublished but cited and discoverable on the Internet,
examined the etiology of trauma in one reservation school
population, using a very creative but valid statistic.
Dr. Morsette was able to identify that it was grief and
loss that appeared to contribute more powerfully mathematically
to trauma symptoms than violence exposure. This is quite
revolutionary as we always screen for violence exposure but
screening for traumatic grief is not part of our standard
practice yet.
I asked Dr. Morsette, at his dissertation defense, why he
did that and he said, it just didn't ring true for me and it
didn't seem to be true for my friends and our people, so I had
to put some science to it.
I would share three recommendations, not the official
position of the University of Montana but my own on what we can
do immediately.
Immediately, we need to make sure that we continue to train
doctoral level MDs and PhDs, clinicians and researchers who are
themselves Native. We cannot achieve our goals of self
determination if in the next generation, it is non-Natives
trying to lead the discussion about policy, research and
practice.
Second, the National Child and Traumatic Stress Initiative
supports 80 funded centers with a budget of about $50 million.
With a budget of about $75 million, that number could increase
to about 120. That network has been extraordinarily effective
across the Nation and extraordinarily effective in addressing
the needs of Native children with trauma.
Finally, I would like to endorse the comment of Director
Enomoto.
Thank you for allowing us to infuse traditional cultural
healing with evidence-based scientific approaches to trauma
treatment. I think that is why we have been able to demonstrate
the results that we have.
I actually never thought I would sit in a setting such as
this and hear a Federal official say that was not only
permissible but encouraged. We really have come a long way.
Thank you.
[The prepared statement of Dr. van den Pol follows:]
Prepared Statement of Rick van den Pol, Ph.D., Director and Principal
Investigator, Institute of Educational Research and Service, the
University of Montana National Native Children's Trauma Center
*The exhibits referred to have been retained in the Committee
files.
The Chairman. Thank you, Rick.
Vernee.
STATEMENT OF VERNE BOERNER, PRESIDENT/CEO, ALASKA NATIVE HEALTH
BOARD
Ms. Boerner. Chairman Tester, Vice Chairman Barrasso, and
members of the Committee, my name is Vernee Boerner. I am the
President and CEO of the Alaska Native Health Board.
I submit this statement for the record. I would also like
to note that ANHB's testimony is supported by the National
Indian Health Board.
Thank you for inviting me to provide input on protecting
our children. We all share in this awesome obligation. No group
this size is more vulnerable, more dependent, or whose
experiences will determine the health and prosperity of our
people.
I sit here before you with two asks that go toward breaking
the cycle of violence and abuse. Repeal Section 910 of the
Violence Against Women Act. We will be watching for the Safe
Families and Villages Act and how that progresses as well.
The second ask is to increase the Indian Health Service
behavioral health funds in a non-grant and non-competitive
manner and confer other Federal resources such as the
Prevention and Health Fund to the IHS.
I am extremely appreciative of my co-panelists who have
painted a picture and have defined so well the impacts of
childhood trauma. I offer to you a face to go with those
numbers.
I was sexually abused from the time I was nine years old
until 14. I lived in fear and silence those years. When the man
who abused me told me that my sister, who turned nine years
old, was ready, I went to the police.
During those years, our family experienced other abuses as
well. The aftermath was also quite devastating. I have to lift
my mother up for her strength and support during that time.
However, my sister went through this during her formative
years. She later became an alcoholic. She too got involved with
abusive men and turned away from the good man in her life.
She died three days before her 29th birthday, not from
overdose or poisoning but because she was trying to quit.
A most painful fact is that my story is not unique. It is
far too common. In Alaska, over 50 percent of Alaska Native
women report having experienced some form of abuse. It is from
these experiences and the women and children in our communities
that I express my gratitude to my Senators, Lisa Murkowski and
Mark Begich, for your work and efforts to repeal Section 910 of
the Violence Against Women Act. Thank you.
Addressing violence against women is a key component of
breaking the cycle and preventing the associated childhood
trauma.
Regarding my second ask, the U.S. Government engages with
tribes on a government-to-government basis seeking input on the
Indian Health Service budget formulation process. Tribes in
Alaska and nationally have consistently identified behavioral
health as a key funding priority.
The increase should not come at the expense of other IHS
services and programs. Its system is already stressed and
plagued by chronic under funding. I do understand the fiscal
constraints that we face as a Nation, but the cost of not
breaking the cycle of violence and abuse is higher still.
Furthermore, tribes have proven to be a good investment and
have demonstrated innovation and capacity in designing and/or
participating in effective projects. I would like to highlight
the efforts of two of ANHB's members.
The Alaska Native Tribal Health Consortium has long engaged
in scientifically rigorous, culturally informed or modified
approaches, one of which is the Alaska Native Adverse Childhood
Experiences Study.
This study is contributing to the general body of knowledge
regarding the unique conditions and impacts that adverse
childhood experiences have in the varied settings throughout
our State.
The second is, the Southcentral Foundation has created the
Family Wellness Warriors Initiative. There are many things I
can say about this program and its integration with others, but
due to the lack of time, I will focus on one special aspect.
It incorporates the men. It seeks to celebrate their
traditional role as protectors and engages them as heroes and
champions.
These are just two of the many approaches out there. They
are doing meaningful work. Please support the efforts and
allocate more resources so that together we can eliminate two
of the most infrequent levels of childhood trauma.
Thank you.
[The prepared statement of Ms. Boerner follows:]
Prepared Statement of Vernee Boerner, President/CEO, Alaska Native
Health Board
Chairman Tester, Vice Chairman Barrasso and Members of the
Committee:
Thank you for the opportunity to provide input for this hearing
addressing one of our greatest charges, our children. My name is Vernee
Boerner. I am the President and CEO of the Alaska Native Health Board
(ANHB) and a member of the Indian Health Service Budget Formulation
Workgroup. Established in 1968, ANHB serves as Alaska's statewide voice
on Alaska Native health issues. Our 26 member organizations deliver
health care programs and services to over 143,000 Alaska Native and
American Indian people residing in the state of Alaska. ANHB's mission
is to promote the spiritual, physical, mental, social, and cultural
wellbeing and pride of Alaska Native people.
By way of introduction, my appreciation for your having this
hearing is personal as I was sexually abused from the time I was 9
years old until I was 14. I lived in silence and fear for all that time
until right before I went to the police. What prompted me to go to the
police was when my sister turned 9 years old the abuser told me she was
``ready.''
In addition, my mother and older brother were victims of domestic
violence, we spent nights at women's shelters, and my younger sister
started to experience the abuse I had and aftermath of the full
breakdown of the family unit. She later became an alcoholic and
involved in abusive relationships. She passed away three days before
her 29th birthday from ``complications due to chronic ethanolism.'' Her
death was categorized as ``Natural.'' I know it is a technical term,
but there is nothing natural about that.
Requests. With regard to preventing and addressing childhood trauma
in Indian Country, ANHB has two asks:
1. Repeal Section 910 (the Alaska exception) of the Violence
Against Women Act (VAWA), and
2. Increase Indian Health Service behavioral health program
funds in a non-grant and non-competitive manner and provide
other federal sources such as the Prevention and Public Health
Fund.
As of the time of this writing, we did not have a copy of the
recommendations of November 18 to the Attorney General regarding trauma
among Native children, but we look forward to reviewing the report and
making further comments.
Repeal of Section 910 of the Violence Against Women Act
We support repeal of the ``Alaska exception'' to the Violence
Against Women Act. While we recognize the unique situation in Alaska,
it is clear that the current system is failing our women and families.
The Tribal governments in Alaska are not able to carry out local,
culturally relevant solutions to effectively address the lack of law
enforcement and prosecution in villages that allows perpetrators to
slip through the cracks. The law enforcement and judicial systems
created and administered by Indian tribes or tribal organizations
within Alaska will be more responsive to the need for greater local
control and accountability in the administration of justice than
centralized State of Alaska systems. (Kastelic, 2014)
We specifically extend our appreciation to Senator Murkowski and
Senator Begich for their support and efforts to repeal the Alaska
exception of the Violence Against Women Act. Thank you also, Senator
Murkowski, for your emphasis on finding increased resources for courts
in Alaska to deal with what would be expanded VAWA authority.
Alaska Native women face domestic and sexual violence in the home
at disproportionate rates and in many cases this violence is witnessed
and/or experienced by children in the home, as was the case in my
family. And sadly, I personally witnessed the long-term effects of
trauma with my sister. According to the National Indian Child Welfare
Association, Alaska Native children made up 17.3 percent of Alaska's
child population, yet they represented 50.1 percent of the
substantiated reports of maltreatment. (Kastelic, 2014). No matter the
challenges, we must endeavor to develop the jurisdictional framework in
Alaska to enable tribal communities to protect our families.
Addressing violence against women is a key component of breaking
the cycle and preventing the associated childhood trauma.
Increase Funding for Behavioral Health
Indian Health Service
The IHS Budget Formulation Process is a government-to-government
consultation process and is reflective of the tribes' own determined
priorities. Behavioral health and Alcohol and Substance Abuse Programs
have consistently been identified as priorities. Funding to these IHS
programs, granted in a non-competitive and non-grant manner, offers the
greatest flexibilities to tribes to exercise self-determination, and
has a track record of success. ANHB urges Congress to enact the Budget
Formulation Workgroup's recommendation that Mental Health funding be
increased by $51.5 million above the President's FY 2015 request for a
total of $134 million.
Tribes think holistically and they have specified that a continuum
of care for both prevention and treatment through integrated behavioral
health programs is needed. Congress agreed, codifying it in the Indian
Health Care Improvement Act (IHCIA). Unfortunately to date, the new
authorities in the IHCIA have not had the appropriations needed to
implement the provisions.
While we can point to the IHS budget increasing in recent years,
those increases are in particular areas--most welcome, to be sure--but
the area of behavioral health has not seen program increases.
Prevention and Public Health Fund
It was encouraging when the Administration proposed as part of the
FY 2012 budget to allocate $50 million of the Affordable Care Act (ACA)
Prevention and Public Health Fund (PPH) for coordinated tribal services
to prevent substance abuse and suicide. The Administration proposed to
administer the program through SAMHSA, with funding being provided to
each applicant tribe and additional funding based on population and
need. While the PPH funding does not need to be appropriated ($17.7
billion over ten years, some of which has been rescinded) because it is
mandatory funding. Congress must allocate from the Fund on an annual
basis, and unfortunately did not allocate the funds for tribes as
requested by the Administration.
We find that funding provided directly to tribal organizations
works better than having it filter through the state or another
organization and allows us to better design services, including the
inclusion of culturally appropriate services. We ask Congress to
allocate $50 million of the PPH Fund to the Indian Health Service for
behavioral health services and that it be on a recurring basis.
Alaska Approaches
Tribal programs in Alaska have taken a variety of approaches toward
preventing and addressing childhood trauma. These approaches are
innovative, scientifically rigorous, and are community and culturally
based. The following are just a few of the activities that Alaska
tribes have implemented.
Alaska Native Tribal Health Consortium
The Alaska Native Tribal Health Consortium's vision is that Alaska
Native people are the healthiest in the world. To achieve this vision,
Alaska Native people need healthy families and healthy communities.
Domestic violence and sexual violence (DV/SV) can profoundly wound
individuals, families and whole communities. It is common to hear that
DV/SV disproportionately affects Alaska Native people. By ensuring we
have reliable data and by monitoring changes over time, we can better
understand which programs and interventions are most successful. The
ANTHC Adverse Childhood Experiences Study adds to the growing
literature and general understanding of the problem. Every child, teen,
pregnant woman, adult, and Elder is precious and deserves to live a
life without violence. Having communities without DV and SV would
contribute to making the vision of Alaska Native people as the
healthiest people in the world a reality. (Alaska Native Tribal Health
Consortium, 2013)
Yukon Kuskokwim Health Corporation
Yukon Kuskokwim Health Corporation's (YKHC) incorporated trauma-
informed services by implementing the Adverse Childhood Experiences
(ACEs) questionnaire, including translating the questionnaire into
Yupik. YKHC's staff is comprised of all Native Alaskans who have
personal experience with trauma. The questionnaire has been given to
each of their clients entering the Crisis Respite Center, and has also
been administered to the general population at several Family Wellness/
Suicide Prevention gatherings in the YKHC area of Alaska. The biggest
reaction from YKHC's clients has been, ``I've never told anyone this
before.'' Many are relieved that someone is asking them about trauma
and is willing to help. YKHC found that the most valuable use of the
ACEs Survey was to open a conversation with the client and begin to
work through their residual responses to trauma. (Bryan)
Tanana Chiefs Conference
Tanana Chiefs Conference (TCC) also uses a Trauma-informed Services
approach, which begins when a new client is screened into the various
programs TCC offers. TCC's approach empowers clients as they are given
choices as to how long, and what kind of therapy they will accept, and
what issues to address. TCC offers early intervention and prevention
therapies as well as longer styles of therapy. This approach builds on
each client's individual strengths and cultural ties, which are seen as
major components to the program. The therapist and clients work
together as equals in developing a treatment plan; if it is determined
that one is needed. The goal is to increase the client's skills to
allow them to manage their symptoms and reactions on their own.''
(Bryan)
Southcentral Foundation
For more than 15 years, Alaska Native people have been leading the
charge to end domestic violence, child abuse and child neglect in
Alaska through Southcentral Foundation's (SCF) Family Wellness Warriors
Initiative (FWWI). SCF's strategies are based on Alaska Native cultural
strengths and bringing back traditional values that are protective of
family wellness. FWWI helps build the capacity of individuals, families
and communities to reverse the trends of domestic violence and child
maltreatment. Over a period of many years, we have been successful in
providing the education, tools and skills needed to bring awareness to
the issues; creating safe environments for sharing and healing; and
initiating changes in attitudes, behaviors, and beliefs.
The work of ending domestic violence, child abuse and child neglect
is too important to keep it within the bounds of a few programs or
services. For broader impact, FWWI is also built into the structure and
design of SCF's Nuka System of Care. Every year, new improvements are
made to the way that trauma and abuse are assessed and responded to
throughout the health care system. (Southcentral Foundation, 2014)
In closing, Alaska Native Health Board thanks you for your
attention to child trauma issues. We believe that repealing Section 910
of the Violence Against Women Act and increased resources for tribal
behavioral health services will substantially help break the cycle of
childhood trauma in tribal communities.
***
Works Cited
Alaska Native Tribal Health Consortium. (2013, March). Retrieved
November 16, 2014, from ANTHC Today: http://www.anthctoday.org/
epicenter/publications/alaskanativefamilies/
dvsaBulletin_2nd_ed_final.pdf
Bryan, M. (n.d.). ATTC Network. Retrieved November 16, 2014, from
http://www.attcnetwork.org/find/news/attcnews/epubs/addmsg/documents/
Trauma_Part_3%20May%2031.pdf
Kastelic, S. (2014). Deputy Director, National Indian Child Welfare
Association. Portland: National Indian Child Welfare Association.
Southcentral Foundation. (2014, January). Southcentral Foundation.
Retrieved November 16, 2014, from Southcentral Foundation: https://
www.southcentralfoundation.com/newsletter/2014JanFebANN.pdf
The Chairman. Thank you all for your testimony. It is very
much appreciated.
We will do five minute rounds. I will start with you, Mr.
Listenbee.
Communities often seek to integrate traditional healing
practice into programs aimed at addressing trauma. Can you tell
me what obstacles exist to allow for traditional healing
programs to happen?
Mr. Listenbee. Senator, we know from the report submitted
by the advisory committee yesterday that incorporating
traditional healing programs into current practices and
therapeutic practices is really important.
We know that one-third of children who have been given an
opportunity to use traditional healing methods or traditional
cultural healing, persons have chosen that over other
approaches. We know that half of the adults have chosen those
approaches over other approaches as well.
We think it is very important. We encourage it and we have
tried to implement that in the various programs that we have
developed throughout the Department of Justice.
The Chairman. You don't see any roadblocks though?
Mr. Listenbee. Senator, as we know from the report that was
submitted yesterday, there are a number of problems and issues
involved with developing new approaches and incorporating
traditional approaches into current practices.
We know these are things that have to be carefully
considered and reviewed. As we go forward in terms of
implementing the recommendations of the report, we expect that
we will be working closely with experts in the field to help
develop more effective approaches.
The Chairman. I would just say that if there are
roadblocks, we need to find out how we can resolve those
roadblocks because I think this could add to the effectiveness
of any sort of programs out there.
Dr. van den Pol, I have a question for you.
Your testimony mentions that new research suggests that
trauma may be tied more to loss and bereavement than to
violence. Can you tell me what that means for Indian Country?
Dr. Van Den Pol. Mr. Chairman, my impression is subjective
and has not been subjected to any kind of systematic study but
in my conversations with many Native colleagues, there is a
vast disparity in the number of deaths of loved ones they have
experienced as opposed to my non-Native colleagues.
This is something that comes up as a surprising matter
anecdotally and I don't know of anyone who has looked at it in
a systematic fashion. When Dr. Morsette was working with
clients in his trauma treatment regimen, he did not ask them,
what is wrong with you. He asked them, what happened to you?
What they talked about was having their grandma die from
cancer or losing a sibling to an accident. It seems that
qualitative research is very suggestive about child traumatic
grief, particularly for Native youth.
The Chairman. I am going to turn the Chair over to Senator
Cantwell.
Senator Cantwell. [Presiding] Thank you.
Senator Murkowski?
Senator Murkowski. Thank you, Madam Chair.
I will be brief. Hopefully the rest of my colleagues can
move forward.
I want to thank all of you, particularly Vernee, for your
testimony. It was truly spoken from the heart.
Know that I am committed. We are going to get this Section
910 repealed, get that done and over with.
I also want to acknowledge Valerie Davidson in the room who
has been on the Task Force on American Indians and Alaska
Native Children Exposed to Violence. I really appreciate your
work on that, Val. Thank you for that.
There has been a lot of discussion about the funding and
how do we make this available through grants. You have
mentioned non-grant, IHS funds. This is going to be a query to
you, Administrator Listenbee.
When we talk about grants, we appreciate the variability of
that funding. The fact of the matter is that not only do our
tribal justice programs have to be adequately funded but they
need to occur on an annual basis. You need to be able to rely
on them.
Right now, our tribes in Alaska do not receive Department
of Interior law enforcement nor tribal court funds. I am
working on that. I am on the Interior Appropriations Committee.
I think we are going to be in a position to perhaps advance
that.
I am wondering whether the Department of Justice would be
willing to put forward a formula-funded structure for tribal
justice programs? We have to be able to have the resources to
provide for this level of safety and security.
Can you at least tell us that you are going to look at it?
We have to make some headway on this.
Mr. Listenbee. Senator, what we know is that we agree with
the advisory committee that the current method for providing
funding for unique financial and criminal justice issues in
Alaska does not really address the concerns. We recognized this
issue some time ago because the tribes brought it to our
attention.
At the Justice Department, we developed the Coordinated
Tribal Assistance Solicitation Process in 2010 and we have been
using that since then. This process allows the Department to
streamline the application process and to more effectively
address specific concerns raised by the tribes.
It also gives American Indian and Alaska Native communities
the opportunity to focus their concerns on their most important
criminal justice and public safety issues and then to develop
innovative programs and evidence-based practices to address
them.
Along with that, Senator, since fiscal year 2011, the
President's Office of Justice Programs Submission of Budget has
indicated and requested a 7 percent setaside that would be used
for this particular purpose.
We are hoping that 7 percent setaside will be coming forth
sometime in the not too distant future.
Senator Murkowski. I would really encourage that. Quite
honestly, folks don't want to hear that we are engaged in more
process. They want to know that we have resources on the
ground. They know that tribal courts are funded in the lower
48; they know that they are not funded in Alaska. That doesn't
make sense to them; it doesn't make sense to me.
We are going to be working on this. We would like the
Department of Justice to be working with us.
Very quickly, Dr. Roubideaux, we have had this conversation
before about our village-built clinic program and the fact that
these clinics do not have the funding. They simply do not have
the funding and yet when we want to make sure that we have
behavioral health aides, when we want to make sure that we have
our community health aides who can be that resource for those
who have been violated, for those who do need that help, we
don't have these systems in place.
I was just in a conversation yesterday where once again, we
are concerned that we are not getting any support from the
Administration on ensuring that our village health clinics are
adequately funded.
We have to have these instruments in place. We have to have
the protective side through the ability to enforce some level
of justice, but we also have to have the health side. You have
got to help us with these village-built clinics. You have got
to help us. Yes?
Dr. Roubideaux. Well, yes, we do want to help. That is why
we have been working----
Senator Murkowski. But we have not seen that through the
budgets put forth by this Administration. We have seen zero
help there. We need you to help us. I am going to be very
direct with that because we are going to demand that you help
us.
We have been very polite and we have waited a long time. In
the meantime, we are losing what we have built.
Dr. Roubideaux. I have heard loud and clear from the
tribes. It is a very important issue for Alaska and I would
like to work with you on that.
Senator Murkowski. It is very important. Thank you.
Senator Cantwell. Senator Heitkamp.
Senator Heitkamp. I have just a couple quick comments.
Thank you all for your work in this very important area and
thank you for your personal testimony. It is so important that
we tell the stories and the truth about what really is going
on.
I have a question. None of you mentioned as a potential
solution better screening of children when they enter the
education system. I am wondering if anyone wants to comment on
whether that is a strategy we are pursuing anywhere and if we
have better diagnosis which gives us a better opportunity for
early intervention and better treatment options and outcomes?
Ms. Boerner. Yes, I do know that the Tanana Chiefs
Conference in Alaska has implemented such a program. I can ask
them to provide more information. I will definitely make sure
we get that to you. I do know they are looking at early
intervention and early screening starting with the school age
kids.
Yes, there are programs out there. I will get more
information for you.
Ms. Enomoto. We are also working on developing clinical
measures as well as epidemiological measures to measure trauma
in primary care settings and other settings where we have
children and adults, as well as in our surveillance instruments
looking at measuring trauma nationwide as it relates to mental
health and substance abuse.
Senator Heitkamp. One of the kind of pushes for this
Committee hearing came out of some work that I was doing in
North Dakota with a woman there who is dealing with treatment
of historic trauma.
Great results are being experienced. When we deal with it
on the front end, we know we have a higher graduation rate,
more secure communities, more secure kids and so this is
something we can't let another generation go and say, we know
you feel our pain, we just want you to do something about it.
This idea that we are working on it in the face of these
statistics is not an adequate response. I think you all know
that.
I will close with that.
Senator Cantwell. Thank you, Senator Heitkamp.
Thank you for your leadership. You have been quite vocal on
the importance of this to Indian Country health overall. We
appreciate it.
I would like to go back to you Mr. Listenbee, about the
CTAS grants, the coordinated tribal assistance solicitation the
Department of Justice does.
I was quoting your statistics about 75 percent of deaths of
American Indian and Alaska Native youth from the ages of 12-20,
that about 75 percent of that is related to assaults, homicide
or suicide. The coordinated tribal assistance solicitation I am
assuming are trying to tackle or get at that issue.
I know in the case of the Tulalips, they had one last year
for over $1 million. I am asking about the metrics that the
department uses to measure the results of those grants. What
are the kinds of activities they are undertaking to try to
lower that statistic of 75 percent?
Mr. Listenbee. Senator, first of all, that statistic is
actually supported and comes from research done by Dolores
Subia Bigfoot, a member of the advisory committee, based upon
studies that she performed. It is a very solid fact.
In terms of what the department is doing, through the CTAS
programs, we have a wide range of efforts that are available to
address this specific issue. Tribes are permitted, in the
various purpose areas, to follow through and address this
particular issue.
One of the specific things we are doing through the Office
of Juvenile Justice and Delinquency Prevention is tribal
healing and wellness courts. We introduced that in fiscal year
2014. There are five courts that have been selected.
Our purpose is to use traditional approaches and culturally
specific approaches combined with basic tenets of drug courts
to help children who have been exposed to alcohol abuse. We are
hoping that will be helpful. It goes up to age 21.
Senator Cantwell. What are some of the measurements you are
using on those grants? How are you coming back and saying, here
is the amount of money we have spent and how are we being
successful with this? What measurements are you using?
Mr. Listenbee. Throughout the Department of Justice and
Office of Justice Programs, we have some very standard metrics
that we use to measure the effectiveness of all of our grants.
We are applying the same metrics to the specific tribal grants
we have also.
Senator Cantwell. If you don't have those today, could you
get them to me or if you have some idea about what they are,
either way?
Mr. Listenbee. We are willing to provide that information
to you.
Senator Cantwell. Okay, but those are being measured you
are saying?
Mr. Listenbee. Yes.
Senator Cantwell. Have you come up with anything you would
like to change based on those metrics?
Mr. Listenbee. At this point in time, Senator, I will have
to get back to you on that. I don't have any metrics
information with me that would allow me to provide you with
specific information about that.
Senator Cantwell. Okay.
Dr. Roubideaux, I wanted to ask you about better
coordination between mental health and other tribal services.
In my State, we are embarking on trying to integrate both
behavioral health and primary care services for the Medicaid
population.
What is happening in Indian Country to try to integrate
those same services?
Dr. Roubideaux. I am glad to hear that because we are very
committed to integrating behavioral health into primary care.
We have our Improving Patient Care Program which is our patient
centered medical home initiative now in 172 sites.
Next month, their training session is going to be on
integration of behavioral health into primary care, making sure
that we can do that so that we can identify and treat these
conditions earlier.
Senator Cantwell. What do you think that means? What types
of services? I have been impressed as I have traveled around
various Indian Country health care facilities. For example, in
Anchorage, the facility there is almost like the community hub.
Everybody hangs out there. That is a very positive environment
where you can see issues of concern or frustration on the
behavioral side may be brought up right in the environment.
I have been to other places where the health care delivery
system is at one end of the community and maybe not even that
frequently used unless someone absolutely needs it.
How are we getting to integration of behavioral health?
Dr. Roubideaux. With our Improving Patient Care Program, it
helps coordinate the team of providers rather than having
mental health over here, primary care there, dental here and
pharmacy there. The whole team of providers is working together
to help have a better coordinated response to helping identify,
diagnose and treat the patients.
It is something that we see as helping. Patients are
telling us that they are more satisfied and that it creates a
more welcoming environment as you described. I think we share
the same vision of that is where we want our system to go.
Through the training we are providing, the structure,
through the accreditation process for patient center medical
homes, we are really hoping that will help us move towards that
goal.
Senator Cantwell. What about programs specifically on the
reservations? What ideas do you have, any of the panelists, for
creating better awareness on tribal reservations and an entry
point for discussion, even if it is just education and training
for tribal leaders or tribal elders or ways to identify
problems?
Dr. Roubideaux. For the Indian Health Service, we do a lot
of training in partnership with tribes on mental health,
alcohol and substance abuse, child maltreatment and all those
issues. They give us opportunities to share best practices.
In a number of our programs, we have a lot of evidence-
based and practice-based programs that can be replicated in
other areas. That includes not only doing the clinical
component of it, but also incorporating tradition and culture
because we really think that is the way we are going to be able
to address these problems more effectively.
We have been using more webinars, tele-behavioral health
and more training to try to make sure that we are not just
training our staff, but community members, tribal leaders and
youth. We are working with the schools as well.
Senator Cantwell. These statistics are so shocking. As my
colleague from Alaska said, she has been to places and I have
certainly been to places where the youth have expressed their
own frustrations.
My question is, what can we do to better orient these
programs to somebody really being on site or integration, in
this case, with the school systems so that these kinds of
concerns, anxieties or pressure points by students from the
behavioral health side can be more directly answered
immediately, brought to the surface, developed or even things
their friends and classmates can say, these are some of the
things that are going on here, this is what needs to be dealt
with.
I see you nodding, Dr. van den Pol. Do you have something
to add to that?
Dr. Van Den Pol. I am not sure that I do. I was agreeing
enthusiastically with your remarks.
I think there is huge potential in schools to address
trauma. One of the early studies of trauma treatment was after
Hurricane Katrina, we were invited to Jefferson Parish to work
in the school there.
One of our counterparts who developed the Cognitive
Behavioral Intervention for Trauma in Schools, Dr. Lisa Jaycox
with the RAND Corporation, evaluated a group of students who
had been through Katrina and were sent to a clinic for mental
health treatment and students who were seen in school who
received the same treatment.
I believe the students in the school were three to four
times more likely to engage with the treatment program than
students going to the clinic.
We know where the kids are and we can get them there.
Sometimes we need consent for certain kinds of treatments but I
think in terms of looking for efficient and effective return on
investments, one setting where we are going to find kids who
have trauma is in schools.
Senator Cantwell. Thank you.
Ms. Boerner, did you want to add something to that?
Ms. Boerner. I do. Within the Indian Health Care
Improvement Act there are unfunded authorities that have been
passed, one of which creates a continuum of care within
behavioral health issues.
One of the recommendations that came from Alaska tribes was
to embark on training and education programs to encourage more
tribal members to enter the field. That is something where
perhaps existing practitioners may be able to develop a program
where they are more present and more a part.
Hopefully we reduce some of the stigmatization that exists
out there so there can be more open, less taboo discussions,
perhaps creating that interest within our youth to enter the
field.
Senator Cantwell. I am sorry, I had to confer with my
colleagues. The Chairman might be returning.
You are saying you think there are certain subjects that
right now there is a problem because people don't want them
more openly discussed and we should be discussing them more
openly?
Ms. Boerner. I believe that we might be able to pique the
interest of our youth if we are more present out there with
these programs and create more of a mentorship, an involvement.
I think there is a lot of stigmatization and a lot of fear
around mental health and behavioral health issues that is a
barrier. It is not something I think many of our youth are even
considering as a possible future.
I think if you get more of the practitioners out there and
involved in a sort of mentoring program, thinking of the long
term effects of having more practitioners and the seventh
generation concept.
What we do today has those lasting impacts. Today, if our
action is if we need something in the immediate, that is
something that perhaps we can do, create a greater visibility
of how beneficial this field can be to our people, then perhaps
we will get those kids involved.
Then down the line our grandchildren's grandchildren will
be more involved and a part of the conceptualization and
creation of those programs.
Senator Cantwell. Not to put you on the spot about it, but
how do you think that is best achieved? How do you think
destigmatizing behavioral health could be accomplished?
Ms. Boerner. One reason why I am open about my own personal
experiences is because it is something that is filled with
taboo and the discussions are not necessarily happening. I am
in a place personally where I feel I can be open and I can
share those things.
I have certain protective factors I think that allow me to
do that and I certainly understand others do not have that but
having and opening that conversation starts to release a lot.
Once people start opening up and some of what I have read from
the Yukon Kuskokwim when they have implemented the ACE study,
some of the members said, I have never shown that before. It is
sort of like an ``aha'' moment.
I think having them out there, having them visible just
creates a natural situation where the conversations are
happening. Once that happens, it starts breaking down those
barriers and builds the understanding.
Senator Cantwell. Thank you for sharing that and for what
you are trying to do to break down the barriers.
Ms. Enomoto, did you have a comment?
Ms. Enomoto. At SAMHSA, since the time of Columbine and the
unfortunate events there, SAMHSA has had a long track record of
partnering with the Department of Education and the Department
of Justice in addressing school violence and working to promote
mental health in schools and prevent violence in schools.
Under the President's Now Is the Time Initiative, we have
started to take that to scale where we want to launch a
nationwide effort to integrate schools, communities and
behavioral health to really promote both mental health
literacy, violence prevention and create positive school
climates in every school in America.
At SAMHSA, we would look forward to partnering with BIE,
with tribes and their tribal schools to expand models such as
Safe Schools, Healthy Students and mental health first aid for
youth in Indian Country.
Senator Cantwell. What do you think the next step is? Is it
an actual agreement with BIE? We clearly see from the
statistics we have a great need. We may be seeing there are
some cultural issues or something that may be blocking us.
Obviously moving to more outreach efforts directly in the
community, you can see they are desperately needed.
Ms. Enomoto. Right. We have begun conversations with BIA.
We would welcome more opportunities to partner with them on
that.
Senator Cantwell. Okay.
Dr. Roubideaux, I would like to ask you about the bed
shortage issue. Obviously, we cannot simply board people at the
county jail. Our State is moving towards trying to deal with
this. How do we deal with the shortage of psychiatric beds in
Indian Country?
Dr. Roubideaux. It is a significant problem you have
raised. It is something we definitely need to work more on. It
is an issue, for example, with youth we have our youth regional
treatment centers in 12 areas but they have a certain number of
beds.
In terms of how we pay for those, we have our Purchase and
Referred Care Program where we pay for the services. As the
funding has been increased over the past few years, thank you
for your advocacy on that, we are able to pay for more
referrals and that would help us pay for more of those services
if beds are available. Bed availability is a huge issue.
Senator Cantwell. Do you have an estimate of what it would
actually take to service Indian Country? Do you have a number
of how many psychiatric beds you actually think we need and
what the distribution looks like?
Dr. Roubideaux. I would be happy to talk with my staff and
get back to you with an estimate.
Senator Cantwell. Thank you.
Let me see if I had any other questions for anyone else on
the panel.
Mr. Listenbee, the advisory committee created by Attorney
General Holder released a report pertaining to criminal
jurisdiction over non-tribal individuals. Obviously, we deal
with the Violence Against Women Act.
What else do we need to do to make sure we are getting
justice for crimes committed against children? Do we need to do
more to reform the system?
Mr. Listenbee. As regards to jurisdictional issues, those
are certainly very important issues. Having just received the
report on November 18th, we are reviewing those recommendations
and trying to make some decisions about how best to address
that particular issue going forward.
Earlier, you asked about suicide prevention. I want to
bring to your attention that we have tribal youth programs that
have been around since 2010. At that time we were funded at a
level of $25 million a year to focus on developing youth
leadership. We have been doing that since then.
Funding has gone down to the $5 million level but we
nevertheless bring young people together, we talk to them about
leadership roles, we have regional leadership groups and
national leadership groups.
At those meetings, we do training on suicide prevention for
all the youth who are involved. This seems to have had a
positive effect on youth as they have indicated to us. We think
this is one of the important ways we can address this issue.
You asked earlier about activities on actual reservations.
We support mentoring programs on reservations. We think these
are also very helpful. We have Boys and Girls Clubs on some of
the reservations.
I would also like to bring to your attention that the
Office of Violence Against Women has more than $30 million in
programs in Alaska. Many of them are in the rural communities
and villages. They are focusing on developing shelters for
women in those areas. Those are some of the only shelters
available for women to address those specific issues.
Senator Cantwell. Thank you.
I have to go vote. I will look forward to following up with
you on the details of those resources. I will turn it over to
Senator Franken.
Senator Franken. [Presiding] Thank you. I guess I am the
chairman. I recognize Senator Franken.
Thank you, Senator Franken.
[Laughter].
Senator Franken. I am sorry I couldn't be here, I had to
vote, obviously but I thank you for your testimony.
I have a question that is open to anyone. I would think Dr.
van den Pol and Mr. Listenbee may have something to say about
this.
This is about the cultural or historic circled trauma as a
concept. What is the history of that in terms of when was that
identified or named or understood to be part of what children
or anyone in Indian Country faces?
I understand it is now included in the list of traumas in
this and this is mainly about childhood trauma but when was
that named? What is the history of that?
Mr. Listenbee. On that matter, I would have to defer to Ms.
Enomoto or to Dr. van den Pol.
Dr. Van Den Pol. Senator Franken, I can't tell you the
first published study that discussed historical trauma. I can
attempt to conceptualize historical trauma with a broader
understanding of trauma.
For example, part of the definition clinically is that
trauma is a personal sense of being overwhelmed by a horrific
circumstance. Two individuals experiencing the same automobile
accident with the same injuries, one may be traumatized and the
other may not.
You have to ask and that is one of the things that makes
early assessment and early screening difficult if a young child
doesn't have the verbal skills to answer questions about
intrusive thoughts or insomnia, for example, whereas an adult
might.
With historical trauma, when we talk to Native people, many
of them express trauma symptoms regarding loss of land, loss of
ancestors, broken treaties, lies that were told and that
distress isn't slight, it is considerable. It is clinically
significant.
While academics currently debate the putative validity of
the concept of historical trauma, Native people experience it
and as a consequence, I am convinced it is real. I don't think
the first publications using that term were more than 20 or 25
years ago. Conversation about trauma began in Vietnam but
trauma in children began really at the end of the 1990s.
Senator Franken. Ms. Enomoto, did you want to speak? Anyone
can speak to this. I am the chairman. Oh, you are the chairman.
I yield myself infinite amount of time.
Ms. Enomoto. Administrator Listenbee noted that SAMHSA has
recently issued a concept of trauma and guidelines for trauma
in practice. In that, we outline three Es for trauma: how to
define the individual experience of trauma. First, there is an
event or a series of events which a person perceives as
potentially life threatening or which result in physical or
emotional harm.
There is the experience of that event. As Dr. van den Pol
noted, it could be how the individual perceives or lives
through that event and then the long term adverse effects of
that event.
For two children who are bullied at school, you might
imagine that one child who is raised in a nurturing home with
safe and stable relationships might have more resilience and
coping skills in order to address that bullying whereas another
child who has been physically or sexually abused, who has
witnessed domestic violence or who has been bounced around from
multiple foster homes might not be able to deal with that
bullying in the same way.
As the science tells us, our bodies are biologically primed
to react to the world as a more dangerous and threatening place
if we have experienced multiple adverse events and we have been
stimulated in that fight or flight mode over time.
You can imagine that historical trauma, while there are
these broad political, social, cultural, legal wrongs that have
occurred, also translate into very concrete actions. The first
reports on the boarding schools, for example, from the 1960s
outlined terrible crimes against young children and families.
In my recent visit to Fort Belknap, I heard a very sad
story about someone's grandmother who was sent away to boarding
school at a very young age. But the gentleman I was talking
with said, but she couldn't read. I said, ``she went to
boarding school, oh, they didn't learn anything there''. They
were subjected to forced labor, to significant abuse, to the
degradation of their culture and their language.
When these young children are removed from their homes for
three, four, five or ten years and then return home, how can
they reintegrate into their families? How can they become
parents when their experience of childhood and their upbringing
was by strangers, by abusive adults, by people who were
supposed to be trusted who actually violated that trust?
Those experiences, while historical, play out in families,
in homes, in communities. Whether it is the historical trauma
of the Holocaust, the historical trauma of slavery or the
historical trauma of the Indian boarding schools, you can see
where those things can play out in the homes of families with
the next generation who grow up to witness people who have
difficulties with attachment, substances, mental illness and so
on.
Senator Franken. Mr. Chairman, may I have a little bit more
time.
The Chairman. [Presiding.] Yes.
Senator Franken. I have no doubt that historical trauma is
a big piece of this. The way you define it was how your actions
affects seven generations down. There is historical trauma in a
lot of different senses. One is what a parent does can
traumatize.
I noticed in your attachments that the definition of trauma
is normal reaction to an abnormal event. These are adverse
childhood experiences we are talking about.
What I wanted to get to is that if the idea of, the history
of cultural trauma, historical trauma is new, I would like to
say that I also think about the absence of cultural identity,
the absence of a language, and the absence of a cultural
identity.
I am Jewish. I am not a terribly devout Jew but I know I am
Jewish and it is very much a part of my identity. I probably
went into comedy in no small part because I am Jewish. It means
a lot to me and who I am.
What I have heard from you and read from you, Mr.
Listenbee, is about culturally sensitive treatments. What I
want to know is how old that is, what is the history of that
and how do we measure, how do we begin to measure the effects
of that, define it and define how we use that because I think
that is terribly important.
Mr. Listenbee. I am not an expert on this issue so I will
make one brief comment about it.
The science of adolescent development has grown
tremendously in the last two decades. Neurosciences have grown.
Our ability to actually watch the brain as it responds to
different types of stimuli, using a variety of new tools that
have come on line in the last two decades.
That science has become powerful enough so that the United
States Supreme Court in several major decisions has relied upon
the science of adolescent development and the neurosciences
that accompany it.
I can tell you that these are new sciences for us. We are
trying and tasked by the various experts with which we deal to
do as much research as we can to better understand how
adolescent development is derailed by trauma. We know that it
is but we don't know always how to get children back on task.
We know that trauma informed care helps but it is still a
new field. We do know we are heading in the right direction. We
know that trauma for American Indian and Alaska Native children
derails their normal development. We know a lot of the things
science is telling us can help us get back on line.
That is enough to be dangerous, but it is what I know and
what I have learned from really great experts when I worked
with the Attorney General's National Task Force on Children
Exposed to Violence.
I would add one other thing. Those experts told us this.
They said that all American children should be assessed to
determine whether they have experienced trauma at every
important juncture, when they go to school, when they go to see
their pediatricians, and if they have experienced trauma and it
has derailed their normal development, what we need to do is
get them trauma informed care.
That is what I know. I know that from the experts but if
you take me farther than that, Senator, I would have to turn to
my esteemed colleagues on the panel to explain the mechanics of
it.
The Chairman. We would love to have you do that except the
next vote has been called, so I think we have to wrap this up.
I know I look like I run the 100 in less than 10 seconds but I
don't.
I just want to thank the panel members for being here.
Those of you who have traveled long distances, a special thank
you. The hearing record will remain open for two weeks. There
will be some written questions. You have been a great wealth of
information, all of you. I just want to thank you all for being
here today.
With that, the hearing is adjourned.
[Whereupon, at 3:53 p.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Ralph Forquera, Executive Director, Seattle
Indian Health Board
Chairman Tester and members of the Senate Committee on Indian
Affairs, my name is Ralph Forquera. I am the Executive Director for the
Seattle Indian Health Board in Seattle Washington. The Health Board is
an urban Indian health organization partially funded by the Indian
Health Service. We provide direct and enabling health services for
urban American Indians and Alaska Natives in Western Washington.
One of the services offered here at the Health Board is mental
health counseling. In the last year, with expansion of the Medicaid
program under the Affordable Care Act, the Health Board has likewise
expanded its mental health services to better serve Indian youth. Over
the years, we have been acutely aware of mental health problems among
our urban Indian youth. Many face enormous social challenges being an
Indian living in a city. This often shows up at school where we
continue to see a high drop out rate among Indian youth and declining
academic performance starting at the middle school. We are also aware
that some Indian youth turn to gangs as a way of finding protection
from bullying, and as a source of identity. For Indian girls, this can
often result in sexual abuse or in some instances, coercion into
prostitution and drugs.
As noted during a recent visit by Chairman Tester to our agency,
urban Indians continue to be a mostly invisible population. Local
resources including law enforcement and the public schools are ill
prepared to address the social and cultural challenges that Indian
youth face. The Health Board itself has limited resources to reach
Indian youth. The fact that they are geographically dispersed
throughout the metropolitan area means that finding Indian youth and
offering emotional support is difficult. For the few that we work with,
we know that there are many that remain without the proper attention
needed.
Urban Indians are often overlooked when legislation regarding
Indians is considered. For example, urban Indians are not included in
the Violence Against Women Act directives for Indian Country. Funding
through the Indian Health Service is limited to the single line item in
the annual budget, so funds allocated for specific Indian health needs,
like mental health, may not be available for urban Indians. We do
receive a small grant for mental health generally from the Indian
Health Service, but the resource is limited. With more than 7 out of 10
Indians now living in cities, according to the 2010 United States
Census, a large number of Indian youth are living in cities without
adequate social, cultural, or clinical support.
Cities provide unique mental health challenges for Indian youth. In
most cases, the small number of Indians in any given region of a major
city makes their presence almost invisible. In schools. there are
seldom more than a feNA students and often, they come from different
tribes with different cultural roots. Because some come from families
where educational success was not likewise achieved, nearly a quarter
of the Indians in the Seattle School District are enrolled in special
education. While well meaning to get extra help for an Indian student,
by placing an Indian youth in special education, the child may find
this label added to other labels that may negatively reflect on their
self-image. These unintended consequences of educational strategies are
only appreciated by the Indian community. Without guidance from the
community to recognize these cultural differences, a school district
may not think to consider these matters when addressing the educational
needs of native students.
While a growing percentage of native youth live in loving homes
with supportive families, others are not so fortunate. In cities like
Seattle, the cost of living is quite high and the educational demands
for reasonable employment are extensive. In this vane, we often find
Indian children without proper parental supervision or living in
conditions that are not conducive to sound mental and emotional health.
Drugs, alcohol, violence, and the insecurity that comes from poverty
afflict a significant number of Indian youth. The ability to
concentrate in school may be compromised by hunger or the emotional
scars of an unsafe life.
Statistics are scarce regarding urban Indians. As a mostly
invisible population, statistics related to Indians in cities is often
lumped in the ``other'' category denying local leaders of important
information to help plan and advocate for assistance. The small number
of Indian youth in any single school district makes educational
assistance difficult. Funding for Indian education, like other safety
net services has declined over the last few decades while need has
grown. Until and unless groups like the Senate Committee on Indian
Affairs demand that local municipalities and other government
institutions collect and analyze data on urban Indians and provide
adequate support, the population will remain invisible and help will
never reach those most in need.
Mental health is a serious health epidemic among Indian people both
on and off reservation. The effects of untreated mental health problems
is witnessed in incarceration, domestic and sexual violence, drug abuse
and alcoholism, suicide, poor school performance, high--school drop out
rates starting in middle school, and the many manifestations that
accompany mental and emotional disharmony. We share the concerns of the
members of the Senate Committee on Indian Affairs that there is a grave
need to expand mental health services for Indian youth. Please remember
as you deliberate that many of these youth live in American cities.
Addressing youth mental health must reach beyond the reservation
boundaries to American cities if the crisis in mental health among
Indian youth is to be effectively addressed.
Thank you.
______
Prepared Statement of Rricha Mathur, Policy Research Associate/Program
Manager, First Focus
Chairman Tester and Vice Chairman Barrasso, we thank you for the
opportunity to submit this statement for the record in response to the
recent Committee hearing on ``Preventing and Addressing Childhood
Trauma in Indian Country.''
The First Focus Campaign for Children is a bipartisan advocacy
organization dedicated to making children and families a priority in
federal policy and budget decisions. Our organization is committed to
promoting policies that serve the best interest and safety of children
in the child welfare system. As you know, child abuse and neglect often
contribute to long-lasting trauma in children and can impede child
wellbeing and healthy development. We are concerned, as you are, by
data and reports pointing to disproportionality in incidence of child
abuse and neglect on Indian reservations and hope we can identify and
promote effective and appropriate programs and services to address
maltreatment for this vulnerable population.
A number of societal factors contribute to child abuse and neglect
on Indian reservations. In 2009, 32.4 percent of American Indian
children under the age of 18 lived in poverty. Unemployment rates for
AI/AN adults are 14.6 percent--almost double that of White unemployment
rates nationally.\1\, \2\ 2 Financial instability can often
strain families and reduce a parent's ability to manage stress and
respond appropriately to a child. It can often mean that a parent feels
unable to meet the needs of his or her child(ren). There is also a high
propensity for sexual violence, substance abuse and trafficking on
tribal lands due in part to a historic lack of law enforcement on
Indian reservations.\3\ AI/AN women are 2.5 times more likely to
experience sexually violent crimes that other women.\4\ These factors
and others place AI/AN children at an increased risk for abuse and
neglect and must be addressed.
A recent Department of Justice report, Ending Violence so Children
can Thrive, authored by the Attorney General's Advisory Committee on
American Indian/Alaska Native Children Exposed to Violence, underscores
the urgent need for additional resources and supports for this
population of children. The Committee found that AI/AN children
experience violence at higher rates than any other race in the United
States and face significant issues due to trauma resulting from
exposure to violence.
''The immediate and long term effects of this exposure to violence
includes increased rates of altered neurological development, poor
physical and mental health, poor school performance, substance abuse,
and overrepresentation in the juvenile justice system. This chronic
exposure to violence often leads to toxic stress reactions and severe
trauma; which is compounded by historical trauma.'' \5\
We fully support the Committee's efforts and would like to
highlight several key recommendations included in its report:
1.3 Congress should restore the inherent authority of American
Indian and Alaska Native (AI/AN) tribes to assert full criminal
jurisdiction over all persons who commit crimes against AI/AN children
in Indian country.
Comment: Tribes must be given the authority to adjudicate crimes in
their territories to deter violence from occurring and to impose
penalties on those who commit crimes against children. The lack of
enforcement by federal authorities to prosecute criminals in these
areas and the powerlessness of the tribal courts to hold perpetrators
responsible has historically attracted criminals to Indian country.
Much of the trauma experienced by AI/AN children is the result of
violence and empowering tribes to carry out justice on their lands will
help reduce the incidence of violence, and therefore trauma and
services needed.
1.4 Congress and the executive branch shall direct sufficient funds
to AI/AN tribes to bring funding for tribal criminal and civil justice
systems and tribal child protection systems into parity with the rest
of the United States and shall remove the barriers that currently
impede the ability of AI/AN Nations to effectively address violence in
their communities.
Comment: Tribal programs are underfunded and many problems with the
judicial and child protection programs cannot be solved until more
money is invested in these programs. The United States, as a trustee of
tribal lands and resources, has an obligation to ensure the wellbeing
of AI/AN tribes. Specifically, increases in funding should be made for
the Department of Interior: Welfare Assistance and Indian Child Welfare
Act On-Reservation Programs and the Department of Health and Human
Service's Promoting Safe and Stable Families and Child and Child
Welfare Services programs.
2.1 The legislative and executive branches of the federal
government should ensure Indian Child Welfare Act (ICWA) compliance and
encourage tribal-state ICWA collaborations.
Comment: A recent policy brief authored by the National Indian
Child Welfare Association identifies ICWA's key requirements as:
1) Encouraging more intensive examination of the efforts to
prevent removals of AI/AN children and rehabilitate their
parents,
2) Improving the identification of tribal and relative
families who can serve as placement resources for AI/AN
children,
3) Increasing access to culturally appropriate services,
4) Clarifying roles between states and tribes in child welfare
matters,
5) Increasing sharing of funding and other resources between
states and tribes, and
6) Stimulating the development of state policy to improve the
effectiveness of services and supports for AI/AN children and
families.
Unfortunately, implementation of these requirements has been varied
and the purpose of these provisions is not being met. Lack of oversight
by federal authorities as well as limited resources appropriated have
made it difficult for ICWA to reach its potential.\6\
2.6 The Secretary of Health and Human Services (HHS) should
increase and support access to culturally appropriate behavioral health
and substance abuse prevention and treatment services in all AI/AN
communities, especially the use of traditional healers and helpers
identified by tribal communities.
Comment: Adults with substance abuse and behavioral health issues
can endanger the lives of surrounding children in their communities as
well as those in their care. Investments must be made in preventative
services to strengthen families so that children are not exposed to
violence, abuse, and neglect in the first place and to empower members
of tribes through resources and culturally appropriate trainings so
they can provide services to their peers. In addition, funding and
access to mental health services by AI/AN children is essential.
Investments should continue to be made in the Children's Mental Health
Initiative system of care grants and the Children and Family Programs
circle of care grants.
Moving forward, we believe the swift and effective implementation
of all of the Committee's recommendations is vital to improving the
lives of AI/AN children.
An all too common response to the violence and trauma AI/AN
children experience is to place them in the foster care system. Yet
there are practice concerns that need to be addressed. AI/AN children
are three times more likely to be reported to child protective services
and twice as likely to remain in foster care for more than two years
than their non-AI/AN peers. For example, in North Dakota, AI/AN make up
9 percent of the population, but 30 percent of the state's child abuse
victims.7 This overrepresentation of AI/AN children in foster care can
be, in part, attributed to a bias in the system, leading child
protective services to view certain cultural practices as child neglect
or abuse, or view AI/AN families as less likely to benefit from family
preservation or alternate response, services and supports that would
keep them out of the foster care system, or even perhaps, that these
families are inherently more likely to be abusive and criminal and
removal of a child is almost always the right choice.
ICWA addresses some of these concerns by recognizing the important
role of tribes in removal and placement decisions and by providing
protections to keep AI/AN families safely together and children
connected to their communities and cultures. However, widespread non-
compliance with ICWA and a lack of adequate services and supports for
American Indian families continues to place high numbers of American
Indian children at risk of removal and entry into the foster care
system.
We are encouraged by Attorney General Holder's December 3rd
announcement that the Department of Justice is launching a new
initiative to promote compliance with ICWA. States are also working to
implement pieces of ICWA into their state codes by incorporating new
AI/AN specific definitions, ensuring notification to AI/AN parents and
tribes of custody proceedings, and increasing collaborations between
states and tribes. States are also issuing guidance to providers and
relevant agencies to encourage compliance with ICWA.8 We hope that
Congress will do its part as well and make the necessary resources
available to aid the Administration in this important effort.\9\
We thank you again for the opportunity to submit this statement for
the record and look forward to working with you to ensure that the
recommendations put forth by the Attorney General's Advisory Committee
are fully implemented.
______________
\1\ Aspen Institute, Fast Facts on Native American Youth and Indian
Country (Sept. 2013), Available at http://www.aspeninstitute.org/sites/
default/files/content/images/Fast%20Facts.pdf.
\2\ Simmons, David, Improving the Well-Being of American Indian and
Alaska Native Children and Families through State-Level Efforts to
Improve Indian Child Welfare Act Compliance (Sept. 2014). Available at:
http://www.nicwa.org/government/documents/Improving%20the%20Well-
being%20of%20American%20Indian
%20and%20Alaska%20Native%20Children%20and%20Families_2014.pdf
\3\ Substance Abuse among American Indian or Alaska Native Adults,
June 24, 2010. Available at http://www.samhsa.gov/data/2k10/182/
AmericanIndian.htm
\4\ Patricia T jaden and Nancy Thoennes, Full Report of the
Prevalence, Incidence, and Consequences of Violence Against Women, pg.
23. Available at https://www.ncjrs.gov/pdffiles1/nij/183781.pdf.
\5\ U.S. Department of Ending Violence So Children Can Thrive,
Attorney General's Advisory Committee on American Indian and Alaska
Native Children Exposed to Violence (Nov. 2014), Available at http://
www.justice.gov/sites/default/files/defendingchildhood/pages/
attachments/2014/11/18/finalaianreport.pdf
\6\ Simmons, David, Improving the Well-Being of American Indian and
Alaska Native Children and Families through State-Level Efforts to
Improve Indian Child Welfare Act Compliance, pg. 4 (Sept. 2014).
Available at: http://www.nicwa.org/government/documents/
Improving%20the%20Wellbeing%20of%20American%20
Indian%20and%20Alaska%.20Native%20Children%20and%20Families_2014.pdf
\7\ Tomothy Williams, Officials See Child Welfare Dangers on a
North Dakota Indian Reservation (July 7, 2014), Available at http://
www.nytimes.com/2012/07/08/us/child-welfare-dangers-seen-on-
spiritlakereservation.html?pagewanted=all&_r=0
\8\ Simmons, David, Improving the Well-Being of American Indian and
Alaska Native Children and Families through State-Level Efforts to
Improve Indian Child Welfare Act Compliance, pg. 9 and 10 (Sept. 2014).
Available at: http://www.nicwa.org/government/documents/
Improving%20the%20Wellbeing%20of%20American
%20Indian%20and%20Alaska%20Native%20Children%20and%20Families_2014.pdf
\9\ Attorney General Eric Holder Delivers Remarks During the White
House Tribal Nations Conference, Dec. 3 2014. Available at: http://
www.justice.gov/opa/speech/attorney-general-eric-holder-delivers-
remarks-during-white-house-tribal-nations
______
Prepared Statement of Gwendolyn Puryear Keita, Ph.D., Executive
Director/Public Interest Directorate, American Psychological
Association
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of the National Indian Child Welfare Association
(NICWA)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Response to Written Questions Submitted by Hon. Jon Tester to
Rick van den Pol
Question. One of the stated goals of the National Native Children's
Trauma Center is to significantly increase the cultural relevancy of
the interventions it disseminates across Indian Country. In its
trainings and consultations, how exactly does the Center work to ensure
that cultural practices are incorporated into treatment for behavioral
health?
Answer. In the thirteen years that we have been treating youth with
trauma in Indian Country, we have seen a positive shift in the
willingness of federal agencies to allow Native cultural practices to
be included in evidence-based trauma treatment.
In about 2003, the 40-year old field of Implementation Science was
not well understood. Implementation Science is concerned with ``high
fidelity'' implementation of treatment protocols. Procedural deviations
were considered methodological and clinical flaws. However, during the
past five years Implementation Science has expanded to include
``treatment optimality,'' and the inclusion of cultural practices has
proven an excellent fit within a framework of treatment optimality
research.
In fact, when we first began including Elders and Healers in
school-based trauma treatment we expected criticism from the field and
from our sponsors for failing to have a high fidelity trauma treatment
protocol. But currently when we speak of treatment optimality, we find
strong support among our peers, editors and grant officials. At the
November 2014 SCIA Oversight Hearing, it was truly dramatic to hear
officials from SAMHSA and OJJDP explain that they uniformly support
treatment innovations that include cultural practices.
``While not conducive to short-term change, we have developed three
developmental approaches that seem to support long term relationships
with Tribes and tribal members. First, we only work in communities
where we have been invited. Second, we consider that all data resulting
from tribal partnerships are the property of the Tribe; the Tribe may
or may not give us permission to disseminate those data. Third, in
addition to protecting individual identity, we do not disclose the
identity of a Tribe unless the Tribe asks us to do so.''
``We also have found it valuable to engage local community members
in participatory dialog regarding their perceptions of the value of
treating childhood trauma, what the outcomes of successful trauma
treatment should look like, and whether there already are traditional
support strategies that could be blended with the evidence-based trauma
treatment. While some local adaptations have been procedural (e.g.,
inviting students to draw a picture to supplement their oral trauma
narrative), we also have invited local cultural experts to contribute
traditional language and traditional healing strategies during group
trauma treatment.''
``In some communities, our early efforts to include traditional
Native language and culture stimulated apprehensions among our tribal
partners. One set of concerns involved the proprietary nature of Native
language and culture. Closely linked were perceptions that researchers
might exploit or otherwise profit from information shared by healers
and Elders. (And because we do this work as part of our university
employment, we cannot completely nullify this perception.)''
``To date, no Tribe has refused our request to share results of
trauma treatment. However, the extent to which we discuss traditional
language and culture follows one of three protocols. Which protocol is
followed is determined by Tribal Council decision with recommendations
from Elders. In the first case, traditional language and healing
ceremonies are made available to children and youth who choose them,
but whether and how that occurs is not disclosed in our dissemination.
In the second case, we report that a community volunteer with expertise
in language and culture participated in the trauma treatment program,
but the intervention(s) he or she used are not recorded, named or
described. In the third case, the traditional ceremony may be named and
may be described. In every case, we inform the Tribal Council of our
findings before disseminating elsewhere.''
(Reprinted from Whitegoat, W. and van den Pol, R. 2014.
Cultural adaptations of trauma treatments in Indian Country, CW
360 Trauma Informed Child Welfare Practice, Winter 2013, 25,
38.)
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Response to Written Questions Submitted by Hon. Jon Tester to
Vernee Boerner
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Response to Written Questions Submitted by Hon. Mark Begich to
Vernee Boerner
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*Response to the following questions was not available at the
time this hearing went to print*
Written Questions Submitted by Hon. Jon Tester to
Kana Enomoto
Question 1. In your testimony you mention your agency recently
awarded 20 Tribal Behavioral Health grants to tribes to develop and
implement plans that address suicide and substance abuse. Do you have
any idea how many tribes currently have a youth suicide prevention
plan?
Question 2. You've been working on trauma with SAMHSA for over a
decade now. What have been some of the biggest steps forward in the
Agency's efforts to address trauma? In your opinion, what still needs
to be done within the Agency?
Question 3. Could you briefly discuss how SAMHSA has made sure that
its programs for Native communities are culturally informed?
Written Questions Submitted by Hon. Tom Udall to
Kana Enomoto
Question 1. I see value in the Tribal Behavioral Health grant
program, where each tribe can develop and implement behavioral health
interventions best suited for their own members. However, with 566
federally recognized tribes, 20 grants do not go a long way. How can
SAMHSA reach more tribes with this program?
Question 2. As research is revealing more effective tools and
strategies for screening and identifying those who have experienced
historical trauma, what is the capacity of the screeners to know how to
respond and refer?
Question 3. Are there sufficient places for treatment that these
children and their family members (if appropriate) can/will be referred
to?
Question 4. What can be done to address the need for effective
treatment as effective screening will increase the demand for such
services?
Question 5. The services, programs and funding of IHS, SAMHSA and
DoJ are all vital to help prevent, identify, refer and treat Native
Americans and Alaska Natives for mental health and childhood trauma
issues. How are these (and any other federal agencies) working together
to coordinate efforts so that tribes benefit from synergy of these
efforts, and that federal definitions, screening tools, practice
guidelines, funding streams and other aspects of these activities are
coordinated, streamlined, flexible and consistent federally?
Question 6. Given the extent of the problem and the actual
appropriations currently available, what proportional increase would be
required to address closer to 90 percent of the need?
Question 7. While biomarker and interview screening can help
identify people at risk for behavioral health problems based on
historical trauma, children re-experience the trauma of feeling
worthless when we send them to schools that are crumbling and unsafe,
and health clinics and hospitals that are dilapidated and out of date.
Question 8. What are you doing to end this form of trauma by
creating environments that reflect the worth and value of Indian
children through every encounter with your services?
Written Questions Submitted by Hon. Mark Begich to
Kana Enomoto
Question 1. It has been noted by HHS's Health Resources and Service
Administration that there are apx 4,000 mental health shortage areas
across the country, many of which are in Native communities.
Question 2. Can you talk a bit about how technology is being
incorporated to close these gaps?
Question 3. How effective has tele-health been in closing these
national gaps?
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Written Questions Submitted by Hon. Jon Tester to
Hon. Robert L. Listenbee, Jr.
Question 1. Childhood trauma is an issue that many departments are
attempting to address. How have agencies and departments ensured
adequate coordination between initiatives?
Question 2. DOJ, SAMHSA, and IHS mentioned using videos, hotlines,
and outreach publicity campaigns to address trauma prevention and
treatment. How are we measuring ``success'' and effectiveness in these
programs and campaigns?
Question 3. How does the shortage of Native mental health care
providers impact the delivery of trauma treatment services?
Question 4. Communities often seek to integrate traditional healing
practices into programs aimed at addressing trauma. What obstacles
exist that limit or prevent the inclusion of such practices?
Question 5. You're funding evaluations in two tribal communities,
including one in my home state of Montana with on the Rocky Boy's
Reservation. Many of our tribal communities in Montana have been hit
hard by the sudden deaths of young people--through accidents, through
substance use, through suicide, and through violence. While I applaud
the effort to build the body of research, how do we ensure that we're
actually making a difference in tribal communities? How are we
measuring success in the face of such extreme and immediate need?
Question 6. How is your office making sure that tribes have the
technical resources to compete for grants--particularly for smaller
tribes?
Question 7. How are the DOJ and OJJDP's Native trauma efforts
reaching Native kids who live off reservation in urban communities?
What resources are available for that population?
Question 8. Unfortunately, the DOJ works with many Native kids who
are both victims and victimizers. What is the DOJ doing to make sure
that Native children held in federal prisons and institutions are
receiving treatment for previously experienced trauma?
Question 9. In August of this year, I held a listening session on
Human Trafficking in Indian Country at the Fort Peck Reservation in
Montana. Although there have been Indian communities struggling against
these heinous crimes for years, in my State of Montana, the uptick in
the trafficking industry is has been truly disturbing. The historical
trauma you mention in your testimony makes our Native communities even
more vulnerable to trafficking. As your office funds the National
Center for Missing & Exploited Children, I'm wondering if you can
provide us some more information on how it is increasing coordination
with tribes to provide them tools to combat against traffickers.
Question 10. Much of the prosecution of trafficking crimes is under
the jurisdiction of States. What type of outreach to State attorneys
general and prosecutors are being undertaken by the Department to
combat trafficking in Indian Country?
Written Questions Submitted by Hon. Tom Udall to
Hon. Robert L. Listenbee, Jr.
Question 1. The services, programs and funding of IHS, SAMHSA and
DoJ are all vital to help prevent, identify, refer and treat Native
Americans and Alaska Natives for mental health and childhood trauma
issues. How are these (and any other federal agencies) working together
to coordinate efforts so that tribes benefit from synergy of these
efforts, and that federal definitions, screening tools, practice
guidelines, funding streams and other aspects of these activities are
coordinated, streamlined, flexible and consistent federally?
Question 2. Given the extent of the problem and the actual
appropriations currently available, what proportional increase would be
required to address closer to 90 percent of the need?
Question 3. While biomarker and interview screening can help
identify people at risk for behavioral health problems based on
historical trauma, children re-experience the trauma of feeling
worthless when we send them to schools that are crumbling and unsafe,
and health clinics and hospitals that are dilapidated and out of date.
Question 3a. What are you doing to end this form of trauma by
creating environments that reflect the worth and value of Indian
children through every encounter with your services?
Written Questions Submitted by Hon. Mark Begich to
Hon. Robert L. Listenbee, Jr.
Question. Mr. Listenbee, I very much appreciate your background on
the various DOJ programs. I see there are a handful of pilot or
demonstration projects currently in place that sound fantastic, but
that are only set up in 2 or 3 tribal communities. How does the DOJ
envision expanding these demo projects over the next 3-5 years, once
there is evidence-based data showing their effectiveness?
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Written Questions Submitted by Hon. Jon Tester to
Hon. Yvette Roubideaux
Question 1. What does the IHS do to recruit and retain mental
health providers that specialize in children's mental health?
Question 2. What is the current vacancy rate for mental health
providers at the IHS? Please provide a detailed breakdown of the
vacancies by region and position.
Question 3. Is the current funding for children's mental health
treatment and youth suicide prevention sufficient?
Question 4. You mentioned the importance of ensuring that efforts
to address trauma in Indian Country are coordinated across agencies.
How does IHS coordinate with other agencies, NGOs, etc., to ensure the
biggest impact is made?
Question 5. Your testimony mentioned a new comprehensive national
Child Maltreatment policy for IHS. When can we expect to see this new
policy rolled out? What initiatives and changes will such a policy
include?
Question 6. How does the IHS attempt to integrate traditional
healing practices into its mental health and trauma treatment plans?
Written Questions Submitted by Hon. Tom Udall to
Hon. Yvette Roubideaux
Question 1. It has been noted by HHS's Health Resources and Service
Administration that there are approximately 4,000 mental health
shortage areas across the country, many of which are in Native
communities. Can you talk a bit about how technology is being
incorporated to close these gaps?
Question 1a. How effective has tele-health been in closing these
national gaps?
Question 2. Dr. Roubideaux, in your testimony you note that IHS has
had over 15,000 tele-health substance abuse and mental health
encounters in the last 5 years. How does IHS measure the success rate
of these encounters?
Question 3. Dr. Roubideaux, you note several times in your
testimony that over 50 percent of Mental Health, Alcohol and Substance
Abuse funds are transferred under 638 contracts to tribes/tribal
organizations that run their own programs. Does IHS have a system in
place to evaluate the success/outcomes of tribally managed programs?
Question 3a. Is there a system in place that allows IHS to
incorporate and design federally managed programs, based on tribal
models that are proven to be effective?
Written Questions Submitted by Hon. Mark Begich to
Hon. Yvette Roubideaux
Question 1. The services, programs and funding of IHS, SAMHSA and
DoJ are all vital to help prevent, identify, refer and treat Native
Americans and Alaska Natives for mental health and childhood trauma
issues. How are these (and any other federal agencies) working together
to coordinate efforts so that tribes benefit from synergy of these
efforts, and that federal definitions, screening tools, practice
guidelines, funding streams and other aspects of these activities are
coordinated, streamlined, flexible and consistent federally?
Question 2. Given the extent of the problem and the actual
appropriations currently available, what proportional increase would be
required to address closer to 90 percent of the need?
Question 3. While biomarker and interview screening can help
identify people at risk for behavioral health problems based on
historical trauma, children re-experience the trauma of feeling
worthless when we send them to schools that are crumbling and unsafe,
and health clinics and hospitals that are dilapidated and out of date.
What are you doing to end this form of trauma by creating environments
that reflect the worth and value of Indian children through every
encounter with your services?
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