[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

=======================================================================


                                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
         
         
         
                                   ______

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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

                              ----------                              
                                                                   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

                              ----------                              


                      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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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]



                                 ______
                                 
     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.)
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Jon Tester to 
                             Vernee Boerner
                             
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                ______
                                 
    Response to Written Questions Submitted by Hon. Mark Begich to 
                             Vernee Boerner


                                 ______
                                 

        *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?
                                 ______
                                 
           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?
                                 ______
                                 
           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?

                                 [all]