[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                 IDENTIFYING, PREVENTING, AND TREATING
                           CHILDHOOD TRAUMA:
                    A PERVASIVE PUBLIC HEALTH ISSUE
                           THAT NEEDS GREATER
                           FEDERAL ATTENTION

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


                                HEARING

                               BEFORE THE

                              COMMITTEE ON
                          OVERSIGHT AND REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 11, 2019

                               __________

                           Serial No. 116-45

                               __________

      Printed for the use of the Committee on Oversight and Reform
      
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                   COMMITTEE ON OVERSIGHT AND REFORM

                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Paul A. Gosar, Arizona
Wm. Lacy Clay, Missouri              Virginia Foxx, North Carolina
Stephen F. Lynch, Massachusetts      Thomas Massie, Kentucky
Jim Cooper, Tennessee                Mark Meadows, North Carolina
Gerald E. Connolly, Virginia         Jody B. Hice, Georgia
Raja Krishnamoorthi, Illinois        Glenn Grothman, Wisconsin
Jamie Raskin, Maryland               James Comer, Kentucky
Harley Rouda, California             Michael Cloud, Texas
Katie Hill, California               Bob Gibbs, Ohio
Debbie Wasserman Schultz, Florida    Ralph Norman, South Carolina
John P. Sarbanes, Maryland           Clay Higgins, Louisiana
Peter Welch, Vermont                 Chip Roy, Texas
Jackie Speier, California            Carol D. Miller, West Virginia
Robin L. Kelly, Illinois             Mark E. Green, Tennessee
Mark DeSaulnier, California          Kelly Armstrong, North Dakota
Brenda L. Lawrence, Michigan         W. Gregory Steube, Florida
Stacey E. Plaskett, Virgin Islands   Frank Keller, Pennsylvania
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
                     Susanne Grooms, Chief Counsel
                          Amy Stratton, Clerk

               Christopher Hixon, Minority Chief of Staff

                      Contact Number: 202-225-5051
                         
                         
                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page
Hearing held on July 11, 2019....................................     1

                               Witnesses

Panel I
Mr. William Kellibrew, Founder, The William Kellibrew Foundation
    Oral Statement...............................................     6
Ms. Creeana Rygg, Survivor and Activist
    Oral Statement...............................................     8
Mr. Justin Miller, Deputy Executive Director, Objective Zero 
  Foundation
    Oral Statement...............................................    10
Ms. Heather Martin, Executive Director and Co-Founder, The Rebels 
  Project
    Oral Statement...............................................    13
Panel II
Dr. Debra E. Houry, Director, National Center for Injury 
  Prevention and Control, Centers for Disease Control and 
  Prevention
    Oral Statement...............................................    24
Dr. Christina Bethell, Director, Child and Adolescent Health 
  Measurement Initiative
    Oral Statement...............................................    25
Dr. Denese Shervington, Clinical Professor of Psychiatry, Tulane 
  University School of Medicine
    Oral Statement...............................................    27
Mr. James Henry, Former Deputy Governor and Chief of Staff, State 
  of Tennessee
    Oral Statement...............................................    28
Mr. Charles Patterson, Health Commissioner, Clark County, Ohio
    Oral Statement...............................................    30
Written opening statements and witnesses' written statements are 
  available at the U.S. House of Representatives Repository: 
  https://docs.house.gov.

                           INDEX OF DOCUMENTS

The documents listed below are available at: https://
  docs.house.gov.


  * Jewish Federations of North America Letter; submitted by Rep. 
  Wasserman-Schultz.

  * Testimony from the Office of Suffolk County District Attorney 
  Rachael Rollins with the Louis D. Brown Peace Institute; 
  submitted by Rep. Pressley.

  * Reports from Orange County organizations regarding services 
  ot homeless families, from the Family Solutions Collaborative, 
  Families Forward, Mercy House, First Five Orange County, Orange 
  County United Way, and Jamboree Housing; submitted by Rep. 
  Rouda.

  * Statement from the National Education Association; submitted 
  by Rep. DeSaulnier.

  * Statement from the National Juvenile Justice Delinquency 
  Prevention Coalition; submitted by Rep. DeSaulnier.

 
                 IDENTIFYING, PREVENTING, AND TREATING
                           CHILDHOOD TRAUMA:
                    A PERVASIVE PUBLIC HEALTH ISSUE
                           THAT NEEDS GREATER
                           FEDERAL ATTENTION

                        Thursday, July 11, 2019

                   House of Representatives
                  Committee on Oversight and Reform
                                           Washington, D.C.

    The committee met, pursuant to notice, at 10:05 a.m., in 
room 2154, Rayburn Office Building, Hon. Elijah E. Cummings, 
(chairman of the committee) presiding.
    Present: Representatives Cummings, Clay, Cooper, Connolly, 
Rouda, Wasserman Schultz, Sarbanes, Kelly, DeSaulnier, 
Lawrence, Gomez, Ocasio-Cortez, Pressley, Tlaib, Jordan, 
Massie, Meadows, Hice, Grothman, Cloud, Gibbs, Miller, 
Armstrong, Steube, Keller, and Maloney.
    Chairman Cummings. The committee will come to order. 
Without objection, the chair is authorized to declare a recess 
of the committee at any time and this full committee hearing is 
convening regarding identifying, preventing, and treating 
childhood trauma.
    I now want to recognize our distinguished ranking member 
for an introduction of a new member of our committee.
    Mr. Jordan?
    Mr. Jordan. Thank you, Mr. Chairman, and I am pleased to 
announce that we have our newest member is Mr. Fred Keller from 
the great state of Pennsylvania representing the 12th District.
    Mr. Keller served in the General Assembly in Pennsylvania 
for over eight years. A wonderful addition to our committee 
and, maybe most importantly, he is married to his wife, Kay. 
They have two kids and, probably most importantly, have two 
grandchildren.
    So we welcome Fred to the committee and look forward to 
working with him to serve the great people of our country.
    Thank you, Mr. Chairman.
    Chairman Cummings. Thank you. I want to too extend a warm 
welcome to our newest member, Fred Keller, who represents the 
12th District of Pennsylvania.
    During his time in the state legislature he demonstrated a 
commitment to open accountable government, focusing on 
transparency. Congressman Keller set an example by posting his 
personal and office expenses online while he worked to 
establish those standards for state government.
    I look forward to working with him on those and many other 
issues and I am pleased to welcome you, Congressman Keller, to 
our committee.
    Thank you very much.
    I will now--did you want to say something? Did you want to 
say something? Huh? Okay. All right. I didn't want to--on your 
debut I didn't want to mess it up.
    [Laughter.]
    Chairman Cummings. I will now yield myself such time to do 
an opening statement.
    Mr. Keller. Thank you, Mr. Chairman. It is such a pleasure 
to----
    Chairman Cummings. Oh. I thought he said he didn't want to.
    Mr. Jordan. I thought he did. I think he did.
    Chairman Cummings. Okay.
    Mr. Keller. Thank you, Mr. Chairman. It is a privilege to 
be here and serve the people of Pennsylvania's 12th 
congressional District and the citizens of the United States of 
America. I look forward to working with the committee and all 
the other Members of Congress to have a positive impact in the 
work we do here in Washington, DC.
    Thank you.
    Chairman Cummings. Thank you. Thank you very much.
    Now I yield myself five minutes for an opening statement.
    When I thought about this hearing I could not help but 
think about the 1997 film ``Good Will Hunting.'' If you will 
recall, in ``Good Will Hunting'' we had Matt Damon and Ben 
Affleck and Robin Williams, and Matt Damon played as a troubled 
youth, and his psychiatrist, played by Robin Williams, was 
trying to help him because he kept getting into trouble. 
Remember that?
    And for some reason, there is one sentence in that entire 
film that I shall never forget. When the psychiatrist, played 
by Robin Williams, went up to the young youth, who had been in 
and out of trouble and had all kinds of problems, and he said 
these words.
    He said, ``It is not your fault. It is not your fault.'' 
And so today we are examining a critical issue that does not 
get enough attention here in Congress or throughout the 
nation--childhood trauma.
    Childhood trauma is a pervasive public health issue with 
long-term negative health effects that costs the United States 
billions of dollars.
    In 1998, the Centers for Disease Control and Prevention 
published a landmark study that found that adults who suffered 
from adverse childhood experiences, also known as ACEs, are at 
a much greater risk of several leading causes of death, 
including heart disease, lung disease, cancer, substance use 
disorder, and suicide.
    The study examined the effects of adverse child experiences 
such as abuse, neglect, or separation from a parent, and it 
also examined the long-term effects that these events have on 
children throughout the rest of their lives.
    The science is powerful. Traumatic experiences can injure 
the developing brains of children, create lifelong impairments 
to their ability to manage stress and regulate emotions, and 
significantly increase the likelihood of negative health 
outcomes.
    As we will hear today, a growing number of researchers, 
medical professionals, public health experts, and government 
officials warn that childhood trauma may be one of the most 
consequential and costly public health issues facing our Nation 
today.
    The CDC recently estimated that cases of substantiated 
child maltreatment in 2015 alone will generate consequences 
that will cost the United States $428 billion.
    As staggering as that may sound, the CDC warns that this 
estimate likely undercounts the true costs to our Nation 
because it examined only some of the types of trauma that 
children experience.
    The good news and the reason we are holding this hearing 
today is that childhood trauma is preventable and treatable. 
The effects of traumatic experiences can be identified, damage 
can be healed, and children who have experienced trauma can 
become thriving and productive adults.
    To do this, we need a comprehensive Federal approach that 
recognizes the severe impact of childhood trauma and prioritize 
prevention and treatment.
    I applaud the efforts of dedicated professionals at the CDC 
and other agencies to address childhood trauma. However, 
efforts at the Federal level are still severely under-funded 
and they do not provide the comprehensive whole-child approach 
we need to combat this crisis.
    Childhood trauma is a nationwide public health issue 
associated with an epidemic of negative health consequences.
    For example, in 2017 substance abuse disorder--use disorder 
and suicide took approximately 150,000 lives in this Nation and 
reduced life expectancy for the third year in a row.
    The Federal Government should be providing national 
leadership and resources to combat this public health epidemic. 
Some states and localities are implementing promising programs 
to help prevent and treat childhood trauma that can inform 
Federal solutions.
    State and local health agencies are on the front lines of 
the childhood trauma crisis. They are confronting many of the 
negative health consequences that trauma produces.
    Sadly, I see this every day in my city of Baltimore where 
far, far too many of our community's children are suffering 
severe trauma, including experiencing or witnessing violence or 
losing parents to violence, incarceration, or substance use.
    As we will hear today, today state and local agencies are 
pioneering innovative interventions to address the crisis, and 
I want to thank all of our partners in this effort.
    The Government Accountability Office has highlighted 
several of these promising efforts. However, it has also warned 
that states are facing limitations in funding, technical 
capacity, and personnel to address this complex and multi-
faceted problem.
    I often tell my staff that when people come into my office 
who are troubled that they must remember that many of the 
problems that they suffer today started when they were a child. 
Started when they were a child.
    And there are two paths of life, I tell them. There is one 
path that is your destiny. The other path is development, and 
you have got to have both.
    And so as a Nation, we have a significant economic 
incentive and, more importantly, a profound moral imperative to 
ensure that our children have the opportunity to thrive and 
succeed. That is why we are having this hearing today, and I 
want to thank all of our witnesses, everybody who is here.
    And now I am pleased to yield to our distinguished ranking 
member, Mr. Jordan, for his opening statement.
    Mr. Jordan. Thank you, Mr. Chairman.
    Let me first thank our witnesses--Mr. Miller and Ms. 
Martin, Mr. Kellibrew, Ms. Aviles-Rygg. Your stories are not 
easy ones to tell and it is brave of you to come here today and 
share them with us.
    In particular, I want to thank you, Ms. Martin. It is hard 
to believe it has been 20 years since that tragic day in 
Colorado.
    The topic of today's hearing is an important one. Childhood 
trauma is something we must all strive to better understand, 
work to prevent when possible, and treat when discovered.
    Our children are, after all, our most precious gift. The 
research shows that traumatic childhood events actually alter 
brain development, as the chairman said, and are linked to 
higher rates of heart disease, mental health issues, that lead 
dramatically to increased rates of suicide.
    Childhood trauma also leads to increased drug use. The drug 
use often results in a life of addiction, which itself results 
in trauma for the children of those affected.
    We now know that devastation of the opioid epidemic is one 
of the most significant factors contributing to childhood 
trauma. My home state of Ohio has the second higher opioid 
overdose rate--overdose death rate in the country.
    These overdoses are ripping apart families and forcing 
children to cope with unspeakable grief.
    I want to thank the chairman for inviting Mr. Charles 
Patterson from Clark County, Ohio, to testify on the second 
panel to shed more light on these issues and what Ohio is doing 
to try to combat them.
    The opioid problem has affected all of our districts, 
especially our colleague, Carol Miller's, district, which has 
been called the epicenter of the opioid epidemic.
    I appreciate all of Carol's work in addressing this 
problem. I also wanted to take a minute to recognize another 
member of our committee. Dr. Green is not yet with us.
    This is his first term in Congress and in his first term 
from the moment he joined the committee he has worked 
tirelessly to address issues related to veterans suffering from 
PTSD.
    And I appreciate the chairman's work on this. I know you 
and Mr. Green have worked together and I do appreciate the 
bipartisan nature of addressing this, looking to see what we 
can do to address this problem.
    Recently, the Subcommittee on National Security held a 
hearing addressing military suicides as well as the Department 
of Defense and Department of Veterans Affairs prevention 
efforts this was due in no small part to Mr. Green's passion 
for tackling this issue.
    While DOD and the VA are collaborating to provide access to 
mental health treatment, Congress has the responsibility to 
oversee this process and ensure our veterans are getting 
everything they need.
    I would also like to thank the CDC and HHS, in particular, 
Dr. Houry, for her testimony today and the extensive amount of 
time their teams have provided to the committee staff to learn 
more about this critical issue.
    I hope we will continue to do this on a bipartisan basis. 
Again, I want to thank our witnesses for traveling here and for 
sharing their difficult stories. It is courageous of you to do 
that.
    And just mention that I may have to step out from time to 
time. We have a subpoena markup on--over in Judiciary. So but I 
will try to be here for as much of the testimony as I possibly 
can.
    Mr. Connolly. You don't need to be there for that.
    Mr. Jordan. Thank you, Mr. Connolly.
    Mr. Chairman, thank you, and I yield back.
    Chairman Cummings. I want to thank you for your comments, 
Mr. Jordan.
    I, too, want to applaud Mr. Green. He has worked tirelessly 
with us to address the issue of suicide in our military, and I 
want you to know that we will work in a bipartisan way.
    I got a little bit emotional when I was reading my opening 
statement because I know where I could have been. I was placed 
in special ed from kindergarten through the 6th grade. Told me 
I would never be able to read or write, and I ended up a Phi 
Beta Kappa and a lawyer.
    So it is emotional for me. This childhood thing is 
emotional, and I have often said it is not----
    Mr. Meadows. And a pretty good chairman.
    [Laughter.]
    Chairman Cummings. And I have often said it is not the deed 
that we do to the children; it is the memory. It is not the 
deed. It is the memory.
    And so now, I would like to welcome our first panel of 
witnesses. The men and women who comprise our first panel have 
each suffered devastating personal trauma and they have turned 
the unspeakable pain they endured into passion to do their 
purpose.
    I am grateful for their presence here today.
    On panel one we have William Kellibrew, who is a founder of 
the William Kellibrew Foundation; Creeana Rygg, who is a 
survivor and activist; Justin Miller, who is the deputy 
executive director of Objective Zero Foundation; and Heather 
Martin, executive director and co-founder, the Rebels Project.
    If you would all--well, you are already rising. So would 
you please raise your right hand?
    [Witnesses were sworn.]
    Chairman Cummings. You may be seated, and let the record 
show that the witnesses answered in the affirmative, and I want 
to let all of our witnesses know that your microphones are 
sensitive. So please speak directly into them.
    And what we are going to do is we are allowing--because of 
the sensitive nature of your testimony we are allowing each of 
you eight minutes or less--or less. Did you hear me? Or less.
    You don't have to take it all. And so--but I beg you to 
stay within it and watch the lights. The lights will come on 
and it will indicate--you know, you have got a yellow light and 
then you have the red light, and then I am going to have to 
bang this gavel. You don't want me to do that so I--and I don't 
want to do that.
    All right. Mr. Kellibrew, thank you.

STATEMENT OF WILLIAM KELLIBREW, FOUNDER, THE WILLIAM KELLIBREW 
                           FOUNDATION

    Mr. Kellibrew. Our values and beliefs drive our 
decisionmaking, actions, and behavior. What we say, what we do, 
how we behave can be directly linked to what we value and 
believe.
    But what if--what if what we value and believe or what 
mattered to us the most was either lost, stolen, withheld from 
us or even destroyed?
    That is what happened to my sister and brothers and me on 
the morning of July 2d, 1984, just days away from our 35th 
anniversary.
    Home alone, I woke up to my mother, Jacqueline, screaming. 
I slowly rose from my bed and looked out of our living room 
window and saw Mom--Jacqueline's ex-boyfriend dragging her and 
my 12-year-old brother down the street toward our home.
    I didn't think much of it. We had lived under his terror 
for months. So I went to find something to eat. Eventually, my 
mom banged on the door and I opened it. She ran toward the 
window, screaming to the neighbors for help, ``Call the 
police.''
    My brother stood against the wall with one foot glued to 
the floor and one against the wall. Mom's ex-boyfriend took out 
a black gun and loaded it, bullet by bullet. He wasted no time.
    He walked over to my mom. She frantically turned to him. He 
pointed the gun to her face and she yelled as loud as she could 
yell, ``No.'' He pulled the trigger.
    He then went to my brother, Tony, put the gun up to his 
head and pulled the trigger. He then walked over to me and 
squatted with the gun to my head in front of me.
    I looked down the barrel and into his eyes and I begged 
fast as I can, ``Please don't kill me. I will do anything.'' He 
didn't respond so I looked up to the ceiling, held my hands 
tightly and begged God, ``Please don't let him kill me. I will 
do anything.''
    An eternity had passed. He pulled the gun back, stood, and 
walked to the other side of the room. After pacing, he said 
that I could leave. But where was I going? This was our family 
living room.
    With my little shorts on and no shoes, I slowly rose from 
my seat and put one foot after another through the threshold of 
our door. After getting further away from our home, I ran as 
fast as I could screaming my mom's words, ``Call the police.'' 
A three-hour standoff, two murders, one suicide. We never 
returned to that rental home in Capitol Heights, Maryland, 
again.
    A loving family member trying to make sense of it all 
patted me on my shoulder and told me before the funeral, 
``Baby, you are going to have to forget about it.''
    My grandmother packed what photos she had, locked them in a 
black and gold chest, and we all tried to forget. I took that 
strategy to the 5th grade, trying to imagine a world much 
different than what I had experienced.
    Three years later in 7th grade, I could not bear the pain 
anymore. I woke up one morning and I put by book bag on and 
headed off to school. I stood on our neighborhood bridge on 
North Capitol Street just 22 blocks away from my seat today, 
having decided to take William Kellibrew, me, out of the 
equation.
    I had lost every piece of dignity I had as a child, my 
voice, my soul, and my purpose empty. I was one decision away 
from relief but I made it to school. My assistant principal, 
Mr. Charles C. Christian, called my grandmother and I was 
hospitalized for 30 days.
    When I was discharged, I met my first ever therapist, 
Christine Pieaerrs. Instead of having the session in her 
office, she took me to the cafeteria at Children's Hospital and 
asked me, ``What do you want for lunch?'' On a one-to-one I 
said to myself, ``I am going to clean you out.'' I started at 
the ice cream machine and I must have built the biggest ice 
cream cone you can build on this side of earth.
    No adult had ever listened so intently to what I had to 
say. It was the beginning of my healing journey and my first 
introduction to the mental health system.
    Thirty years later, I sit here reminded of the long journey 
of hope, healing, and resilience. I stand today alongside my 
fellow survivors with a sense of purpose, dignity, and respect 
for the shoulders I stand on and a sense that healing is 
absolutely possible.
    Two professors from my university, the University of the 
District of Columbia, where I earned my first degree, started 
the William Kellibrew Foundation in 2008. They recognized my 
passion for service and invested in supporting victims of crime 
and my career as a victim and survivor advocate.
    Today, I have taken my passion to my role as a director for 
the Office of Youth and Trauma Services at the Baltimore City 
Health Department, where my mom was born in the 1950's.
    I am afforded the opportunity to work alongside brilliant 
and dedicated colleagues and under the leadership of the city's 
health commissioner, Dr. Letitia Dziraza, to continue to build 
a trauma-informed and responsive city at the forefront of a 
national violence, trauma, opioid, and substance use epidemic 
claiming precious lives each day.
    We have trained over 3,100 city employees, community 
members, small businesses, and nonprofits in a trauma-informed 
approach and now we are working to ensure a longer-term impact 
with solid metrics in place.
    The journey for me, like so many children, young African-
American males, and families I engage in Baltimore and D.C. and 
across the country is not an easy journey of recovery.
    My grandmother, who is sitting here today, said to me as a 
little boy, ``If you can handle your mom and brother's death, 
you can handle anything.'' I didn't know what she meant by that 
at age 10, or 21, but I held on to her faith because I did not 
have much growing up. I had hoped that she knew what she was 
talking about.
    When I first started my job in Baltimore, I met a young boy 
around the age of seven who had been shot in his head. He was 
playing in his neighborhood as nothing had happened.
    He told me a story, but what I took away was that while 
lying in the hospital fighting for his life he said that he was 
trying to stay alive for his family.
    Families cannot be left to grapple with the aftermath of 
trauma. We need sound support through leadership and 
governance, effective policies and practices, mental health and 
substance use supports and treatments, a knowledge base in 
addressing trauma, and the caring and compassion that I know we 
are all capable of delivering that can reduce the stigma of 
experiencing trauma, mental health, and substance use 
challenges.
    Trauma can strip us of our values, our voice, and our 
dignity. Trauma can be dehumanizing. But our role as survivors, 
as human beings, is to bring humanity back into its space.
    That is what the U.S. Congress has done today. Thank you to 
the Honorable Congressman Elijah Cummings and to the honorable 
congressional colleagues and staff of the Committee on 
Oversight and Reform.
    And I have always wanted to say this. I yield my time--my 
time to my grandmother, who worked on her job for 38 years, was 
late less than 10 times, and never used an alarm clock, with a 
mission to give her family a chance at life.
    Please just stand and be recognized, to my grandmother 
behind me. Will you stand please?
    [Laughter.]
    Chairman Cummings. Please stand up.
    [Applause.]
    Mr. Kellibrew. Thank you.
    Chairman Cummings. Thank you for your statement and thank 
you for recognizing that beautiful lady that just stood up. 
Thank you, and thank you for being here.
    Ms. Rygg?

        STATEMENT OF CREEANA RYGG, SURVIVOR AND ACTIVIST

    Ms. Rygg. I would first like to thank Congressman Cummings 
and Ranking Member Jordan, and the members of the House 
Committee on Oversight and Reform for this opportunity to speak 
about the lasting effects of childhood trauma.
    I am 28 years old and from Helena, Montana, where I have 
lived for most of my life. I am Portuguese, Filipino, and 
Hispanic. My family is all from the Hawaiian Islands and moved 
to the mainland before I was born in hopes to give my mother, 
who became pregnant with me at the age of 16, a fresh start and 
a chance at a better life.
    Both my grandmother and my mother are victims of abuse. 
Neither of them had ever received help or justice for their 
trauma. In fact, abuse became something that wasn't 
acknowledged in our family because it was considered normal or 
the price you paid to be supported and have a place to live.
    My mother's first marriage was to a man who physically and 
verbally abused her. Although she tried to shield my siblings 
and I from it, we witnessed her being hit, shoved, and even sat 
on by him in order to prevent her from being able to leave.
    After several escape attempts, she finally got us away from 
him. I was nine years old at the time and we settled down in a 
new town where she met her second husband, Raul.
    Raul was kind to my mom and seemed to love my siblings and 
I. However, as I got older, he changed. I was 11 years old when 
Raul began abusing me. It started with him groping my body in a 
sexual way and pretending he mistook me for my mother.
    At the time, I didn't know that this was a form of sexual 
abuse and I didn't know how to tell my mom. I didn't want to be 
the one to break up our family after all we had already been 
through.
    As the abuse continued, I began to distance myself from 
him, which made him lash out at me in violent ways. He once had 
beat me so badly that our neighbors had heard my screams and 
called the police.
    This was my first open case with the Department of Family 
Services. They came and took pictures of the bruises all over 
my body and Raul was arrested.
    But, unfortunately, the case was closed and he was back in 
our home by the next week. By the time I was 12 years old I was 
so depressed I had stopped eating and was beginning to self 
harm.
    Still unable to tell my mom what was going on, she became 
worried and had me admitted into a children's hospital. There, 
I was diagnosed with bipolar depression and heavily medicated 
for three months until I was behaving well enough to go home.
    I was released, and just before my 13th birthday Raul raped 
me. This time, I did tell my mom and we went to the police. I 
was examined at a hospital and Raul was arrested the next day.
    They found him with scratches all over his face and body, 
just as I had described, as I fought to be free. All of the 
evidence of what he had done was there. But he knew my mom 
could not live with herself knowing she had allowed me to get 
hurt.
    He knew she was vulnerable from the day that he met us and 
he manipulated her once again into believing I was just a bad 
child trying to ruin her happy life for my own selfish reasons.
    Eventually, she was in denial that he had ever done 
anything wrong and I was taken by DFS and placed in group 
homes. I was on juvenile probation and then I lived in foster 
care before being placed in the Florence Crittenton Home for 
pregnant teens.
    I was 14 years old and four months pregnant when I arrived. 
It was at Florence Crittenton that I was finally treated for 
the traumatic experiences that I had survived.
    I attended therapy sessions and I learned that more than 
half the girls living there at the time were also survivors of 
sexual and/or violent crimes.
    After my case had gone to trial and Raul was sentenced to 
prison, I was able to go back home with my mother. Everything 
had happened so fast and now I had a baby to take care of. Mine 
as well as my mother's mental health was put on the back 
burner.
    We did what we knew best and we moved forward. Raul was 
unable to hurt me anymore but I still lived in fear every day. 
I had a hard time developing healthy relationships as an adult. 
I had major trust issues with every man that came into my life, 
including my third step-father.
    I was 22 years old when I met my husband, Jason, and I was 
still having night terrors regularly. My husband would have to 
calm me down and help me back to sleep and it took me years to 
be calm in my own house and not jump every time he walked up 
behind me.
    We are now raising three children together and, like any 
parent, I fear that the worst could happen to them. I try to 
have open conversations about abuse with them so that they can 
recognize it if they experience or witness it and help them 
understand how they can tell someone.
    I am determined to end the cycle of abuse in my family with 
me. I am now involved in national advocacy work for young 
parents and survivors of adverse childhood experiences through 
National Crittenton.
    I have held group meetings at my local Crittenton agency 
where I share my story and give the participants a safe 
judgment-free space to talk openly about their experiences and 
I try to support them in their journey to healing.
    Looking back, I feel as though I slipped through the cracks 
in the agencies that are designed to protect children from 
trauma. I was labeled as a troubled youth when really I just 
needed someone to recognize I was being hurt.
    Sexual abuse is an epidemic in our Nation. Studies have 
found that up to 89 percent of sexual abuse victims are female, 
and of all the females raped in the U.S. 41 percent are under 
the age of 18.
    For youth who are involved in the juvenile justice system, 
the girls' rate of sexual abuse is four times higher than the 
boys in juvenile justice, and the girls' rate of complex trauma 
is nearly twice as high.
    What Congress can do to help is make sure that schools, 
foster homes, group homes, and juvenile justice facilities 
provide services that support girls in healing from experiences 
that cause trauma they faced and make a change from just 
looking at what we did and ask first what happened to us.
    Hundreds of thousands of girls will and have faced similar 
experiences as I did and they each deserve a chance to be 
valued, respected, and supported when asking for help in 
healing. They deserve a chance to live happy and healthy lives.
    Thank you for listening to my story. I hope it will provide 
insight to this subject and a sense of urgency to provide more 
resources to survivors of traumatic experiences.
    Chairman Cummings. Thank you very much.
    Mr. Miller?

    STATEMENT OF JUSTIN MILLER, DEPUTY EXECUTIVE DIRECTOR, 
                   OBJECTIVE ZERO FOUNDATION

    Mr. Miller. My name is Justin Miller. I am a veteran of the 
United States Army. I was medically retired after serving over 
11 years in the military and I am now serving our veterans and 
their loved ones as a civilian.
    I am the deputy executive director and co-founder of the 
Objective Zero Foundation. We are a 501(c)(3) that has created 
a free app that instantly and anonymously connects veterans, 
service members, their family members, and caregivers to one of 
almost a thousand of our trained suicide prevention ambassadors 
in a time of need.
    I faced many challenges growing up as a child of divorced 
parents. I was exposed to many things at a young age that I 
shouldn't have been. I had several instances of childhood 
trauma that I knew weren't normal to most, but I hadn't 
realized the impact they had on my life until I became an adult 
and started seeking help to deal with my PTSD and depression.
    In the fall of 2018, I went to a program called Save a 
Warrior where they gave me the adverse childhood experience 
test. It was then I realized or I remember playing doctor with 
these girls as a kid. There were three sisters who lived nearby 
me. The middle sister was old enough to be developing but the 
youngest sister was my age.
    The middle sister would have us get undressed and play 
doctor with each other at the age of four. I was later 
threatened by their father when he found out and punished by my 
parents.
    Then other inappropriate moments with an adult came a 
couple years later. My best friend accidentally shot and killed 
himself when we were in 4th grade. I was supposed to be at his 
house that night.
    By doing group therapy in school, I mentioned that, and how 
things could have been different. Someone then said it was my 
fault because I didn't go over to his house, and that always 
stuck with me.
    My dad went to prison for three years when I was seven. I 
would always get laughed at because my dad didn't make it to 
Career Day at school.
    When my dad finally did get out of prison, I would do 
anything to have that bond with him and gain his approval. At 
11 years old I was introduced to marijuana and alcohol in the 
same day by my dad. He wanted me to do the things he was doing 
with him so that I wouldn't tell on him for doing them.
    When I was in the 7th grade my 18-year-old uncle hung 
himself in the basement of his house. I was a wreck. My 
teachers could tell something was wrong and sent me to the 
office.
    I started to open up to my counselor and told her what had 
happened. She asked me if I could say one last thing to him 
what would it be and how did I feel. I told her I didn't know 
what to feel. My dad always told me boys don't cry, that if I 
wanted something to cry about he would give me something to cry 
about.
    Before I could even think about it, the lunch bell rang. 
She said, "well, there is the lunch bell. You should probably 
go. Think about what it is I said," and she walked me to the 
door.
    After my traumatic childhood I tried to stay numb and 
intoxicated all the time. During SAW is when I realized I was 
repeating the cycle with my children and then decided it was 
time to break that cycle.
    I went to war for the first time at the age of 20. I spent 
a total of 27 months in Iraq between two deployments. During 
that time, I was involved in many explosions, causing back 
injuries and traumatic brain injuries. I saw things that one 
should never see - that leave me with nightmares, depression 
and anxiety.
    I was also left behind in a house during a mission and had 
to physically fight to get back to my men. I was later punished 
and pushed to another platoon to save them. This left me with 
trust and abandonment issues.
    Two deployments had me feeling completely broken and like a 
piece of me will always be missing no matter how hard I try to 
put myself back together.
    One of the major events that sticks in my mind was 11 
November of 04 when a VBID killed Staff Sergeant Huey. A young 
boy and his sister were also killed in front of me. I also had 
to shoot a warning shot at a man that was carrying his son that 
was critically wounded and later died.
    That warning shot crushed me. I felt like I took everything 
away from that man and it destroyed my life.
    Not long before that day those two kids were playing in an 
alley when we were on a dismounted patrol. As we were walking 
toward them, they grabbed our hands and started pulling us in a 
different direction.
    We called the interpreter after setting security and found 
out that there was a bomb buried in the middle of the road that 
we were about to walk over, and these two little kids with no 
worry of their own safety pulled us aside and let us know, 
saving all of our lives.
    It has been torture knowing that I wasn't able to do the 
same for them in return. That specific incident changed me or 
changed things for me as a father for years to come. I believe 
that if I wasn't able to help those kids how would I ever be a 
good father to my own.
    For years I tried to stay distant to my two young kids. I 
had a short fuse with them. When they would cry they would 
trigger old memories from war and I would become angry.
    I made myself believe that they would be better off without 
me. However, SAW taught me that the best way to help others is 
to help yourself.
    Once you learn the process and understand that childhood 
trauma wasn't your fault, you then begin the healing process. 
This healing process will affect seven generations in the past 
and seven generations ahead.
    Once I realized it was okay to talk about what I have been 
through and started dealing with my PTSD, my relationship with 
my kids started to change.
    I now make an effort to make time for my children and 
connect with them over things that they are passionate about, 
i.e. coaching their softball and baseball teams.
    I also make an effort to remind my children that they are 
enough, that I am proud of them, and that I fully support them 
in the paths they choose. I want them to know that they should 
never feel that they need to do anything life to gain my 
approval.
    I make it a point to start conversations with them about 
random topics so I can get an insight on the people they are 
becoming. This also makes them more comfortable to sparking up 
future conversations with me.
    My hope is for more veterans to open up about the struggles 
they are dealing with day to day so we can end the suicide 
epidemic. My nonprofit, Objective Zero, was started after I 
almost took my own life.
    I felt like I had no one to talk to that would understand 
what I was going through at the time. Because of my darkest 
moments, we created an app to do just that. Nearly a thousand 
people have signed up to lend a nonjudgmental ear and talk 
through the hard times with those who have dedicated their 
lives to this country.
    It is going to require a culture shift for us to see a 
difference. People need to quit feeling ashamed and embarrassed 
about their trauma. By not talking about our trauma, it gives 
that event power over you.
    The more we talk about these issues, the more people will 
feel open to asking for help and talking about their struggles.
    What made the difference for me is when I was going to 
church looking for an answer and I was having it down right out 
with God and I was mad at him.
    And I heard clear as day, quit feeling sorry for yourself. 
Look at everything I pulled you through. What good is it to 
know an answer to a secret if you keep it a secret? Share your 
struggles to give others hope and strength to push forward.
    Thank you.
    Chairman Cummings. Thank you very much.
    Ms. Martin?

STATEMENT OF HEATHER MARTIN, EXECUTIVE DIRECTOR AND CO-FOUNDER, 
                       THE REBELS PROJECT

    Ms. Martin. Thank you so much for listening to my story.
    On April 20th in 1999, I was a senior at Columbine High 
School when two gunmen killed 12 students, a teacher, and then 
killed themselves.
    Today, I am approaching my seventh year as a high school 
English teacher and I am also the executive director of a 
nonprofit called the Rebels Project, named after the Columbine 
Rebels.
    It supports survivors of other mass traumas. It took me a 
little over 10 years to confront and reflect on how the 
shootings at my high school impacted me. But I have learned 
some valuable lessons.
    One that sometimes needs reminding is that trauma recovery 
has no timeline. Another is that we can help by providing 
children with the tools to support them as they build 
resilience.
    During the shooting, I was barricaded in a small office 
with 59 other students while the gunmen rampaged the school. 
Three hours after barricading we were escorted out by SWAT team 
members and passed the bodies of two students who were shot 
outside, Danny Rohrbough and Rachel Scott.
    Much later, I learned that the SWAT team, thinking there 
were still gunmen loose in the building, decided to save us 
instead of seeking out Dave Sanders, who eventually bled to 
death just a few rooms down the hall from where we hid.
    Sometimes these details are enough for the average person 
to be horrified enough to keep their judgment of my recovery to 
themselves. However, many times I still find myself having to 
justify the depth and complexity of my trauma and why I 
struggled for so long.
    Later that evening, I arrived home physically uninjured but 
a completely different person. My sister, a freshman in 1999, 
hugged me in the driveway, feeling grateful and guilty that she 
got out of the school relatively quickly.
    I graduated and went off to college where I experienced 
being blind-sided by a trigger for the first but certainly not 
the last time.
    You see, what didn't remember was that the fire alarm had 
been going off while I was trapped in the office. So when the 
fire alarm sounded in my English class to signal a drill, 
instead of evacuating like everyone else, I started sobbing 
uncontrollably.
    I tried to advocate for myself to my professors and was 
told I still had to write my final English paper about school 
violence or fail the class, even after confessing that I had 
been at Columbine.
    I ended up failing that class and actually I failed English 
class twice in college, which makes my students now laugh. My 
first semesters of college were some of the hardest times in my 
life.
    After being surrounded by loved ones and by a support 
system made up of people who understood what I had gone 
through, I was now embarrassed, shameful, and isolated.
    I was also really angry, not surprising to anyone who knows 
anything about grief or trauma. For me, the manifestations of 
that trauma were that I developed an eating disorder and I 
tried drugs.
    The drugs were fairly short lived and, lucky for me, they 
weren't addictive. As for my sister, she just celebrated three 
years clean and sober and will continue to fight each day for 
her recovery through her trauma and through her drug abuse.
    I did attend formal therapy and received validation from my 
therapist, someone my family was lucky enough to afford, that 
it was okay that I was traumatized even a year later.
    Silly me. I thought I should have been over it in months. 
Eventually, I dropped out of college completely and I worked 
full time. For anniversaries I went out of town to avoid the 
memories, much like many of my students feel now when they are 
reminded of the traumas they have experienced.
    Once I had a student who stopped coming to class because 
the anniversary of their traumatic experience was approaching. 
Later, they told me that they had to buildup enough courage to 
come talk to me about it because they were so embarrassed. I 
imagine this is similar to how I felt when I attempted to talk 
to my college professors.
    Other tragedies also impacted me. 9/11 sent me into 
hysterics and prompted severe flashbacks. Virginia Tech 
resulted in several debilitating anxiety attacks and I 
embarrassingly had to call into work. I mean, that was even 
eight years after the attacks at Columbine.
    Though the company I worked for was pretty understanding, I 
could tell that there were frustrations when I couldn't show 
up.
    In 2009, 10 years after the shooting, I reconnected with 
people who knew what my struggles entailed. As a result of 
these renewed connections and acceptance I felt when returning 
for the anniversary, I went back to college.
    At first, my brother had to come to campus with me to help 
me navigate and feel comfortable. But, eventually, I was a full 
time student again, majoring in English and working toward my 
secondary teaching license.
    Now my struggles were mostly in math because I teach 
English.
    [Laughter.]
    Ms. Martin. After co-founding the nonprofit in 2012 and 
having the opportunity to travel and connect with other 
survivors across the country, I began to see more clearly the 
ripples of trauma and the similarities that exist no matter the 
circumstances of the event.
    Columbine and my story are often sensationalized, one of 
the reasons I imagine I am here today. But the feelings I 
experienced in the months and years following Columbine--anger, 
loneliness, isolation, and embarrassment--are not unique to 
mass shooting survivors.
    For my students who have been traumatized in other ways, no 
less valid or less seriously--they are sometimes too young to 
be able to reflect on why they are reacting the way they are.
    Survivors are blind-sided by triggers all the time. Right 
now, the survivors in my support network who are from more 
recent shootings are asking about fireworks and how long it 
will be until they stop diving for cover.
    For children and for my students, they may be blind-sided 
while reading a short story or they might tune out and stop 
listening to instructions. They may need choices of topics to 
research, to write about, or to study in order to avoid their 
freak outs.
    I have also heard countless stories of survivors trying 
drugs and alcohol to help them numb the pain and blur the 
memories, and not many of my students' families can afford 
therapy like my family could. The school therapists' schedules 
is always jam packed and many of those who could benefit from 
therapy are embarrassed about it because the stigma and many 
times they have convinced themselves or have been convinced 
that whatever they are going through doesn't warrant therapy.
    I also consider how triggering events might impact my 
students. Would they react like me and avoid talking about it? 
Would they react in anger and in defiance?
    These questions and concepts are explored during trauma-
informed professional development so teachers can best support 
the needs of their students.
    As a teacher, I wear many, many hats. But I am not always 
qualified to provide the support needed. Schools need more 
counselors, more social workers, and more psychologists. They 
need programs that teach children how to build resilience, how 
to avoid or--I am sorry, how to use coping skills and how to 
practice self care.
    At my school, we average one counselor to every 400 
students. Increasing these services will not only help children 
who have experienced trauma but also help provide the skills 
necessary to build resilience before a traumatic event.
    Trauma is, in fact, a universal part of the human 
experience and because of this universal experience, it is 
critical that we address this underlying issue that connects 
many of our current problems. Trauma is connected to suicide, 
to abuse, to drug addiction, and even to classroom management 
issues.
    Please consider these needs in order to ensure that all 
children who need mental health support in schools and in 
communities have access and not just after a traumatic event 
but before as well.
    In closing, and I understand that this might be really hard 
to do, but please do not compare our traumas and our 
experiences on this panel. Our stories and experiences are very 
different. But trauma is trauma across the board.
    Chairman Cummings. Thank you very much.
    Let me, before we go into questions because I want to be 
clear--I want the witnesses to be clear and the witnesses 
coming up to be clear--you will see members going in and out.
    It is no disrespect to you. It is because on Wednesdays and 
Thursdays is when we have our hearings and all members that I 
know of sit on at least two committees and a lot of it is 
conflict.
    They are conflicting with each other. There are votes. And 
so we want to make sure you are clear. It is not out of 
disrespect but, you know, we try to do more than one thing at a 
time.
    I also want to let the members know that to ensure that we 
have time to hear from all of our witnesses and out of respect 
for the highly personal stories that the members of our first 
panel have just shared with us, we are limiting questioning to 
this panel to a total--listen up--a total of 10 minutes, total.
    And I just want to also thank our ranking member for his 
cooperation in working this out. You have been extremely 
helpful and I deeply appreciated all that you have done to help 
us out.
    With that, I am going to--and let me show you how we are 
going to do it. I am going to just have one question and then I 
am going to go to the other side. I am going to flip back and 
forth until we have exhausted 10 minutes on both sides.
    All right. You got that? So if you are going to ask a 
question we need to know that you are going to ask one, and if 
we don't get to you don't be mad. We are just trying to respect 
our witnesses, all right?
    All right. I am going to be quick.
    Mr. Kellibrew, I want to thank you for being with us today. 
Mr. Sarbanes and I, of course, represent Baltimore and we are 
always trying to figure out ways to help young people and go 
through what they are going through and difficulties.
    In your experiences both of trauma survivor and as a 
practitioner working with traumatized youth in Baltimore, let 
me ask you this. How critical is expanding services to help 
prevent trauma and support children who have experienced trauma 
to enabling Baltimore to reduce the violence in our city?

                          STATEMENT OF

    Mr. Kellibrew. I think it is extremely important and I 
think that building on the strengths of our young people is 
important. I think realizing that our young people have the 
innate ability to succeed.
    I actually was once in special education as well and I 
didn't believe that I could get out there. Failed many times in 
college and high school. Didn't graduate. Got my GED. But here 
I am leading a public health approach in the city that my 
mother lived in and was born in, and I think that believing in 
our kids and modeling what resiliency looks like I think is an 
important thing in our programs that we have at the health 
department and across the city, ensuring that they are 
consistent trusting programs and that they have the metrics 
behind them to show that they actually work and then believing 
in community.
    The community has the ability to do that. So the 
partnerships and collaboration is part of a trauma-informed 
approach. So collaboration is really important all across the 
board.
    Chairman Cummings. I now yield to Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman.
    Again, I just want to thank the witnesses for your courage 
and your story and for your service--Mr. Miller, your service 
to our country, all of you, of your service to students, the 
impact you are having on people and to your families.
    We had this wonderful grandmother introduced, but I think 
we have got other family members for the other--I know we have 
a husband here and Mr. Miller and maybe Ms. Martin, if you have 
family here I think the chairman would probably like for them 
to stand up too so we can all recognize them if you have----
    Chairman Cummings. Absolutely. You all--any of you all have 
family here please----
    Mr. Jordan. Yes. Thank you.
    [Applause.]
    Mr. Jordan. Thank you all for coming. I yield back, Mr. 
Chairman.
    Chairman Cummings. Very well.
    Ms. Wasserman Schultz, for one question?
    Ms. Wasserman Schultz. Yes. Thank you, Mr. Chairman.
    Ms. Martin, thank you for--Ms. Martin, I am over here. I am 
over here.
    [Laughter.]
    Ms. Wasserman Schultz. Yes. It is a very broad dais. I 
really appreciate you sharing your story. I represent the 
community directly adjacent to Marjorie Stoneman Douglas High 
School.
    So our community has been through really a very similar 
trauma and we are dealing with the aftermath of students who 
also survived, and there will be many years that that is--those 
are challenges that we are going to have to help them through. 
So your being here is really important.
    And I could hear the resilience through the pain in your 
story. I have not experienced trauma myself so it is difficult 
for me to directly sympathize. I can certainly empathize.
    But, first of all, it is incredible that you became a 
teacher--that you--that you put yourself professionally in a 
school environment and that that is where you go to work every 
day and are nurturing our young people.
    So I want to ask you my question based on your experience 
as a teacher. Can you share more about why you think it is so 
important that we provide training and resources to enable 
teachers to recognize trauma and support children who have 
experienced it so they don't get the reaction that you got from 
your college professor?
    And like I said, I know that we are struggling to make sure 
that we can do that for our students in Broward County as well.
    Ms. Martin. Thank you for your question.
    I have been down to speak to the students several times.
    Ms. Wasserman Schultz. Thank you.
    Ms. Martin. They are hanging in there.
    Ms. Wasserman Schultz. Yes.
    Ms. Martin. They are right where they should be.
    Ms. Wasserman Schultz. They should--absolutely.
    Ms. Martin. To your question, at my school we have an 
extremely diverse population. So our professional development 
sometimes vary from what I hear goes on at different schools.
    But it is so important for teachers at every school to take 
part in these professional developments and they need to be 
meaningful because professional developments for teachers are, 
like, just check the box, like, oh, I have to go to this 
meeting and sit there and listen.
    But they need to be aware, I think, that because a student 
is acting out in class or challenging you, there is a good 
chance that it is not--it is not you. It is not something that 
you are doing. It is something that they have been through, and 
it is so critical that teachers understand that and reflect on 
that because the ripples of that can--I mean, it can change a 
child's life.
    If you can connect with a child--I mean, if they are acting 
up, like, instead of writing them a referral or sending them 
out you just say, are you okay today--what is going on today. 
And chances are they are going to open up.
    I tell them my story every year, and the purpose for that 
was I just wanted them to take, like, lock down drills 
seriously, and the unintended consequence of that was that they 
opened up to me about their stories and then I was able to put 
them in touch with the appropriate resources.
    So teachers and really anybody in the education field 
really needs to be educated on trauma-informed instruction and 
what that looks like and what that means.
    Ms. Wasserman Schultz. Thank you very much.
    Chairman Cummings. Mr. Massie?
    Mr. Massie. Thank you, Mr. Chairman.
    Mr. Miller, thank you for your service but, more 
importantly, thank you for signing up to help the people who 
have served and the people who have gone through experiences 
like all of you have shared.
    Could you just briefly tell us a little bit more about this 
app that you worked on that could help other people who are 
contemplating taking their own lives?
    Mr. Miller. Yes, sir.
    So the night that I almost committed suicide it was 4 
o'clock in the morning. So you don't want to be a burden to 
somebody. I had no clue who to talk to so I just tried to do 
what I was always told, just to suck it up, drink water, and 
drive on.
    So after calling the VA, telling them that I almost killed 
myself, was placed on hold, scheduled an appointment for two 
days later, I just felt like I was completely abandoned.
    A phone call from an old leader lasted about six hours and 
he kind of just gave me a different purpose and a direction. So 
we got my story published. You know, let others know that they 
weren't alone.
    The app idea was given to us. Originally, it was like Yelp 
for veterans. But while doing research, I found that most 
veterans, when they decide to commit suicide to do it within 
the first five minutes.
    So, really, we don't have time for them to try to find a 
resource, call, be put on hold, sent a voicemail. We are, like, 
we need something that is instant. And people that are active 
duty are afraid to go get help, you know, because if you get, 
you know, diagnosed with PTSD you are non-deployable. Once you 
are non-deployable they don't need you anymore.
    So we are, like, you know, we need something that is 
instant and anonymous, something that they can just pick up the 
phone, touch of a button, be connected to somebody who cares. 
Not there for a paycheck; somebody who just wants to listen to 
you and let you know that you are loved and how important you 
are and how needed you are.
    So right now we have almost a thousand trained volunteers 
that are there just to answer a phone. We have over 4,000 
people that are using the app. Like I said, touch of a button, 
voice video or a text, they can instantly connect with 
somebody. The app is live. So if it is 2 o'clock in the 
morning, you open the app, you can see who is available to 
answer that call.
    Mr. Massie. Can you--can you tell us the name of the app 
before I yield back my time?
    Mr. Miller. Objective Zero.
    Mr. Massie. Thank you very much, Mr. Miller.
    Chairman Cummings. Thank you.
    Mr. Miller. Thank you.
    Chairman Cummings. Thank you.
    Mr. Connolly?
    Mr. Connolly. Thank you, Mr. Chairman.
    I just want to say to all four of you, I have been to a lot 
of hearings. This is the bravest panel I have ever heard.
    Chairman Cummings. Thank you.
    Ms. Kelly?
    There is nobody on there. I am sorry. Is there anybody----
    Ms. Kelly?
    Ms. Kelly. I just wanted to thank all of you, first of all. 
I used to work at Crittenton Care and Counseling Center in 
Illinois, believe it or not, and part of that was I worked with 
parents who had the propensity to abuse their kids--to stop 
that cycle.
    Mr. Miller, I too wanted to thank you for your service and 
your commitment to this country.
    What kind of supports do you think would help other parents 
suffering from the effects of trauma to break the cycle with 
their own children?
    I know you, you know, have SAW but everyone is not, you 
know, a military person. But what would you recommend?
    Mr. Miller. My recommendation is to make the ACE exam more 
common. It needs to be given to children in school, you know, 
by a counselor so that way the teachers and the counselors 
understand, you know, why a student may be acting out the way 
they are.
    And along with parents. I had no idea all the trauma that I 
went through. I just thought that I had a normal childhood 
until I had this test and then everything started coming back 
to me.
    And, you know, the ACE exam they say if you score a four or 
higher you are, like, 50 percent more likely to commit suicide 
than your average citizen, along with the drug addictions and 
all that.
    So I think having even the parents and the families know 
and understand that, you know, this stuff happened, people 
might have just thought you are doing it and you are being a 
troubled child, you know, years ago.
    But now, if they would have just said, well, let us look at 
the root of why he is doing these things. You know, why were 
these girls even having these ideas? Who was doing this to 
them?
    Where did they learn this from, you know, instead of just 
jumping straight to the conclusion of you were doing something 
wrong and punishing them. You know, try to figure it out, talk 
to them, and then you let them know that, you know, this isn't 
your fault. It shouldn't have happened. But we are going to 
talk about this. We are open about let us work through it as 
a--as a family, just to get give them a better understanding.
    Chairman Cummings. Thank you very much.
    Mr. Hice?
    Mr. Hice. Thank you, Mr. Chairman.
    And I just want to reiterate and say thank you, each of 
you, for being here today and sharing your stories, and for 
family and friends who are here as well.
    Ms. Martin, you are so right that every story is different. 
My background--I was a pastor for over 25 years before coming 
to Congress and cannot tell you how many people over the years 
that personally we have been involved with and trying to help 
through multiple different kinds of traumatic experiences.
    And hearing your stories this morning, quite frankly, is 
difficult for me just in reliving so many other experiences in 
precious people's lives that we have personally been engaged 
with.
    And every time, to be honest, I felt so inadequate and I 
cannot--I mean, just like in every person's life that we dealt 
with I was just crying out to God for wisdom to help--to help 
these people in whatever circumstance it was.
    And so thank you to each of you.
    Mr. Miller, I do want to specifically ask you--you 
mentioned personally an encounter you had with the Lord and, 
you know, I look--just personally going back and back in the 
1990's, I believe it is, only about 7 percent of Americans said 
they had no religious affiliation. Now that is well over 20 
percent, and I think that is rather significant.
    I was just curious how important your faith was in dealing 
with and finding some healing from the traumatic experience you 
went through.
    Mr. Miller. If it wasn't for my faith, none of this would 
happen. I was--my leadership--my friend, Chris, tried to 
convince me to write my story and I procrastinated. I didn't 
think I had a story. I just thought that I was in the infantry 
and did my job.
    So it wasn't until my mother-in-law asked me to come to 
church, and I was, like, why. You know, what type of God would 
actually let this crap going on in the world? What type of God 
would let me see this stuff and survive?
    What type of God would let my friends die and me make it 
back and have to suffer and remember this all my life? And I 
was having it down right out with him.
    I was cussing him out and I heard it clear as day, you 
know, and once I heard that I am, like, I have to share my 
story. I mean, how do you have someone tell you that with 
nobody around and then not go home and do it?
    And that is when I realized that, you know, our stories 
provides healing for others. It lets others know that what they 
are going through is not--you know, they are not alone, that 
there is others out there that experienced it. So, you know, my 
religion has been key.
    It has helped keep my family together. It has given me the 
belief that if you just wake up every day and put one foot in 
front of another that things will eventually work out as long 
as you don't quite.
    Chairman Cummings. Thank you very much.
    Ms. Pressley, this will be our last----
    Mr. Hice. Mr. Chairman, can I finish my five minutes?
    Chairman Cummings. No, you don't have five minutes. You 
weren't here at the beginning. I limited it. We were--we have--
so that you will be clear, we gave each side 10 minutes and 
each--and I asked members out of due respect for them and--this 
was already worked out and--okay?
    All right. This will be our last person.
    Ms. Pressley?
    Ms. Pressley. Thank you, Mr. Chairman, first of all, for 
your partnership with my office in scheduling this hearing. In 
my eight-year tenure on the Boston City Council I convened 
seven hearings on trauma because it takes many iterations and 
manifestations and because it is all interconnected. Violence 
begets violence and trauma begets trauma, and so many families 
and communities like my own are passing along, unfortunately, 
the legacy of intergenerational trauma.
    I thank each of you for being here. In order for us to work 
on it we have to first speak on it. But one of the things that 
I think stands in the way of our speaking on it is the stigma 
and the shame that survivors carry when it is not your shame to 
carry.
    As hard as it is for people to conceive of the fact that 
someone they love could be traumatized or violated in such an 
egregious way, it is harder for us to accept that there are 
people in our own family and our community and in society that 
we know that could perpetrate such vile acts.
    I was just wondering if you could speak to and, first of 
all, I also just want to say it is so important--I am sorry you 
have to weaponize your pain in order for this survivor tribe to 
be seen and to be heard but it is so critical that this work be 
survivor led.
    But could you just speak to the stigma aspect and how that 
is a barrier to addressing what is a public health--a pervasive 
public health issue in our country?
    Ms. Rygg?
    Ms. Rygg. I know I really believe that the stigma around 
not talking about trauma within your families and with my 
family it was you just kind of moved on. The women in my 
family, going back to my grandmother, they didn't work. They 
didn't support themselves, and so it was kind of just something 
that you dealt with and that is kind of what carried through my 
family, and the importance of just being open with it and 
having open conversations.
    That is what I am trying to do with my children and to 
share my story with other survivors and with young parents with 
what I am doing with National Crittenton within the YPAC is to 
help other parents understand that aside from being a young 
parent if you have that trauma in your life that is also 
something that you need to address in your life and share with 
your children so that they know and are aware if they do see it 
and recognize it.
    And I think the importance of making sure that we have 
those resources and that we can heal ourselves first so that we 
can help heal the next generation is extremely important.
    So with National Crittenton that is the one thing that we--
that I really pride myself that we are working in and that 
group is just making sure that we are there to support each 
other through that healing first so that we can help others and 
help our children heal.
    Chairman Cummings. Thank you very much.
    Let me--we will now--we are going to change panels. But let 
me say this before you go.
    I agree with my distinguished colleague from Virginia, Mr. 
Connolly. This has been some of the most chilling testimony 
that I have heard in my 23 years in Congress.
    But I want to leave you with a message. You know, when bad 
things happen to us, we should not ask the question why did it 
happen to us but we should ask the question why did it happen 
for us.
    I know that is a tough one. I know it is tough. But, you 
know, when I think about you, Mr. Miller, and what you are 
doing today, and the idea--Mr. Miller, there is somebody--in 
all of you there is somebody watching you right now on C-SPAN 
whose life is going to be saved.
    And I know that, you know, you may say, I paid a high price 
for this to save somebody's life. But I guarantee you there is 
somebody.
    And Mr. Kellibrew, there is a little boy who has 
experienced the same thing in Baltimore where we live who is 
saying, you know what, I think I can get through this. I think 
I can.
    And so to you, Ms. Martin and to Ms. Rygg, the idea that 
you would come in and lay some of the most personal things in 
your life on the table so that the world can understand it.
    And so sometimes I think that when you--when you are going 
through all of this, remember my words--I love these words--
pain, passion, purpose.
    You have gone through a pain and many of you are still 
going through pain. It leads you to your passion to do your 
purpose. A lot of the people that are sitting behind you--I 
notice you got family members here--they have gone through this 
pain with you, right? Am I right?
    They have been supportive. And you know what? Guess what? 
They have learned to be even more compassionate. You got me?
    So I want you to know that you are--I know it is hard to--I 
know it is hard to--for this to get through. But you are gifts 
that keep on giving, and we need you to continue your advocacy.
    And, Mr. Miller, you said something that I just can't let 
this go by because I would feel like I had committed 
malpractice if I didn't. You said there came a point in your 
life where you wondered, who needs to hear my story, or, you 
know, do I want to really share this story.
    Yes, you need to share--all of you need to share your 
story. Maybe you need to write a book. I am serious. So that 
somebody can see what you went through and how you got to where 
you got to.
    And, finally, let me leave you with this. There is nobody 
who has lived the life that you have lived. You have lived it. 
A lot of people come and talk about--you know, they write 
theses and all this kind of stuff.
    No, you have lived it. But, more importantly, you are 
willing to share it, and more important than that, you are 
willing to make somebody's life better.
    And we all--we all appreciate you.
    All right. Did you have something else, Ms. Rygg?
    All right. Thank you very much. We are going to move on to 
the next panel.
    [Applause.]
    Chairman Cummings. We are going to go to our members, we 
are going to start back in three minutes. Three minutes.
    While we are waiting, I want to thank the committee for 
adhering to our time limitations on the first panel. You have 
been very helpful.
    Do we have everybody? Castanova, do we have everybody?
    All right. All right. Kelly?
    Our second panel is comprised of Federal, state, and local 
officials and medical experts who will discuss the prevalence 
and--you may--you can sit down for the time being--discuss the 
prevalence and the consequences of childhood trauma and the 
steps that we urgently need to take to address this epidemic.
    I would like to thank all of our witnesses but I especially 
want to thank Dr. Houry from the CDC. I know that there is a 
general preference for agency witnesses to sit on their own 
panel. So I really appreciate you working with us to make this 
happen.
    I hope this hearing will be a continuance to be 
informative, collaborative, and productive. We are honored to 
have all of these extraordinary individuals before us today on 
both panels.
    Dr. Debra Houry, director of the National Center for Injury 
Prevention and Control, Centers for Disease Control and 
Prevention, will be our first witness.
    Dr. Christina D. Bethell, director of Child and Adolescent 
Health Measurement Initiative, Johns Hopkins Bloomberg School 
of Public Health, which is located in my district; Dr. Denise 
Shervington, clinical professor of psychiatry, Tulane 
University School of Medicine; Dr. James Henry, former deputy 
Governor and chief of staff, state of Tennessee; and Mr. 
Charles Patterson, health commissioner, Clark County, Ohio.
    Now, if you would all please rise and raise your right 
hands.
    [Witnesses sworn.]
    Chairman Cummings. Let the record show that the witnesses 
answered in the affirmative. Thank you, and you may be seated.
    I remind you--I guess most of you were in the room 
earlier--but the microphones are very sensitive. Your 
statements will be limited to five minutes.
    Please know that we already have your written statements 
but we are, basically, looking for a summary of your most 
significant points and I beg you to stay within that five 
minutes.
    You have a lighting system, as I explained a little bit 
earlier, and now we will hear from Dr. Houry.

STATEMENT OF DEBRA HOURY, DIRECTOR, NATIONAL CENTER FOR INJURY 
PREVENTION & CONTROL, ON BEHALF OF CENTERS FOR DISEASE CONTROL 
                         AND PREVENTION

    Dr. Houry. Good morning, Chairman Cummings, Ranking Member 
Jordan, and members of the committee. Thank you for bringing 
attention to the important problem of childhood trauma, and 
thank you to the brave survivors who just shared their stories 
with us.
    I am Dr. Deb Houry, and as an emergency physician, I was 
honored to join CDC in 2014 as the director of the National 
Center for Injury Prevention and Control.
    In the ER I have seen firsthand the impact that trauma has 
on children. I still remember the toddler I saw for fever and 
cough. When I looked at his chest x-ray and diagnosed 
pneumonia, I almost missed the multiple fractures he had on his 
rib x-ray. It became clear he had suffered trauma over a long 
period of time. I did my best to console him and contacted 
Child Protective Services to assess his home environment and 
safety.
    And cases like this kept me up at night and I wished I 
could have prevented this and other childhood traumas. Now I 
know, by focusing on prevention and building the resilience of 
our communities, we can meet the immediate needs of those 
already affected, reduce the long-term effects of trauma, and 
prevent trauma.
    Major sources of childhood trauma are called adverse 
childhood experiences, or ACEs. Examples are child abuse and 
neglect or witnessing violence, mental illness, or substance 
misuse in the home.
    As the number of ACEs increases, so does the risk for long-
term negative effects on learning, behavior, and health. CDC 
research shows that more than 60 percent of American adults 
have experienced at least one ACE and almost a quarter of 
adults have experienced three or more.
    ACEs have been linked to the leading causes of death 
including suicide and drug overdoses, shortening a person's 
life-span by almost 20 years.
    The total economic costs of ACEs is conservatively 
estimated in the hundreds of billions of dollars each year. 
There is a need for action to prevent ACEs and their health and 
social consequences.
    As the Nation's public health agency, CDC is positioned to 
lead coordinated efforts to prevent ACEs. This starts with 
using data to understand the scope and burden.
    Our state-based behavioral risk factor surveillance system 
is a key source of data. Recent analysis of these data found 
some groups are at high risk of experiencing ACEs and should be 
prioritized for prevention and response efforts.
    In addition to collecting data, we work with health 
departments to prevent ACEs in their communities. For example, 
we released several resources that include evidence-based 
strategies communities can use such as encouraging and 
developing positive parenting skills and providing quality care 
and education early in life.
    We also fund an Essentials for Childhood program where 
states can use community-level strategies to prevent child 
abuse and neglect, a major contributor to ACEs.
    In Washington, a coalition of schools, city government, 
social services, and law enforcement launched an initiative to 
raise awareness of ACEs and brain development, and to foster 
resilience.
    This lead to the community adopting trauma-informed 
practices in schools, increasing community awareness of ACEs by 
fivefold, and reducing expulsions in the high school by 85 
percent in a year.
    CDC also works with the Office of National Drug Control 
Policy to fund public health public safety interventions at the 
local level. One example, the Martinsburg Initiative in West 
Virginia is an innovative police-school community partnership 
focused on identifying children with high ACE scores and 
linking them to necessary resources and supports to prevent 
future opioid misuse.
    To date, nearly 400 school staff have been trained in ACEs 
recognition and trauma-informed responses.
    Understanding ACEs is essential as we collectively pursue 
strategies to address two of the most pressing public health 
threats facing our nation--overdose and suicide.
    The connection between ACEs, substance use, and suicide can 
lead to a continuous cycle for generations. By preventing ACEs 
through coordinated comprehensive strategies, we can avoid 
exposure in future generations.
    CDC and public health bring a unique and important 
perspective to ACEs prevention and can help communities 
implement strategies that promote safe, stable, and supportive 
environments for children and families.
    CDC is committed to working with Congress, other Federal, 
state, and local agencies and partners to address these complex 
issues and, ultimately, to save lives.
    Thank you.
    Chairman Cummings. Thank you very much.
    Ms. Bethell? Dr. Bethell?
    Your mic is not on. We really want to hear you.

STATEMENT OF CHRISTINA BETHELL, DIRECTOR, CHILD AND ADOLESCENT 
                 HEALTH MEASUREMENT INITIATIVE

    Ms. Bethell. I got it. Okay.
    Good morning----
    Chairman Cummings. Good morning.
    Ms. Bethell [continuing]. Chairperson Cummings and Ranking 
Member Jordan, and members of the committee, and thank you for 
inviting me here to speak with you today and for your 
leadership on this important issue.
    As you know, my name is Christina Bethell. I am a professor 
at the Bloomberg School of Public Health at Johns Hopkins 
University and also a board member of the nonprofit and 
nonpartisan Campaign for Trauma-Informed Policy and Practice.
    I am also a person with lived experience of the majority of 
childhood traumas that are measured in the ACEs study and a 
grateful recipient of nearly every Federal program supporting 
vulnerable children and families.
    The science of ACEs and resilience shine a light on the 
importance of the moment-by-moment relational experiences of 
children to their healthy brain, body, and social emotional 
development not only of our children but our entire population.
    The science requires a paradigm shift in how we think about 
child development, human health, social problems, and the 
skills and requirements for our own well being, which we can 
learn.
    Like an eddy in a river that stops the flow of water, we 
now have, through biological research, understand that trauma 
also stalls healthy brain, body, and social emotional 
development of children, and these impacts cut across life and 
across generations.
    We then go on to diagnose, medicate, treat, and the 
illnesses that are often very predictable - outpicturings of 
unhealed trauma without any awareness of their origins, the 
biologic drivers of this, or the possibilities for healing.
    When enough people such as the two-thirds of adults in the 
country and nearly half of U.S. children are exposed to ACEs, 
we have what we call a synergistic epidemic where we can't deal 
with what ails us unless we also deal with the long reach of 
trauma and proactively promote relational health, emotional and 
stress regulation skills and all of the factors essential to 
health and well being.
    Addressing childhood trauma and promoting well being is our 
greatest public health challenge and in this work we are the 
medicine that we need. We must foster ``through any door'' 
cross sector strategies to build engaged healthy communities 
that work together, shift social norms to support healthy 
parenting, eliminate stigma and shame, and build a trauma-
informed work force, and in this we need a stronger and more 
robust Federal policy response.
    We are fortunate today that many people understand these 
issues but most do not. It is still new. Just last month, in a 
room of 600 early education, health care, and social service 
workers, only 30 raised their hand that they had ever heard of 
the adverse childhood experiences study, and upon learning it 
they realized the lack of coordination among them, all of whom 
served the same families, were re-traumatizing the families and 
also by not engaging the families and ignoring the issues that 
they knew, once they learned about it, were really the 
underbelly of the problems the families faced.
    So while ACEs connection and change in mind and many of our 
other systems engage hundreds of communities, most communities 
are not engaged and need much more support for data, 
measurement, training, personnel, and research.
    So my written testimony includes much more data and 
recommendations related to the committee's area of jurisdiction 
in each of the areas.
    But before I close, I do wish to mention just a few more 
recommendations related to our growing evidence base. First, we 
need a population wide approach. This is all of us. We need an 
era of experimentation and investment to build personnel and 
shift our work force.
    We need quality well childcare services and early care and 
education as our top opportunities to prevent and mitigate 
ACEs, and we need to invest in building a national caring 
capacity that is trauma-informed. We also need immediate shifts 
in Federal-supported programs and services that can perpetuate 
trauma unwittingly.
    Family centered coordinated services across health care, 
legal, education, and social service systems are needed but are 
often blocked by Federal policies or lack of leadership.
    We also need access to high-quality what we call neuro 
repair and other methods that can reestablish disrupted neural 
connections and rebuild the often lost capabilities and skills 
for something as simple as recognizing your own body and 
emotional experiences, re-frame disruptive thinking that can 
perpetuate trauma, and recognize impacts on self and others.
    So, to close, the distinct fields of science are coming 
together to create an integrated science of thriving and we 
need to use the knowledge and tools we have of all of them and 
conduct rapid cycle research to drive innovation and 
implementation, shift how we train, incentivize, and pay for 
programs impacting our population's health and well being.
    I feel very fortunate to live in a time when our science-
lived experience and now our policies will meet to catalyze an 
epidemic of well being that will place the U.S. in the top 
rather than the bottom few of developing countries in child 
well being.
    Grateful to be part of your leadership toward creating a 
well being nation and I look forward to your questions.
    Chairman Cummings. Thank you very much.
    Dr. Shervington?

    STATEMENT OF DENESE SHERVINGTON, CLINICAL PROFESSOR OF 
        PSYCHIATRY, TULANE UNIVERSITY SCHOOL OF MEDICINE

    Dr. Shervington. Chairman Elijah Cummings, Ranking Member 
Jim Jordan, and other distinguished members, I am deeply 
humbled and honored to testify before such an esteemed group of 
leaders who have come together as concerned Americans to 
address this troubling and ever-growing epidemic of childhood 
trauma.
    I also would like to pay my respect for those who came 
before us being so willing to share their pain.
    I applaud your efforts and hope that I can add a little bit 
of science and maybe much more about my underground experience 
to assist in the decisions that I know that you will make.
    My colleagues before have talked a lot about the ACEs so I 
am going to skip that. But what I would just like, there is a 
metaphor that keeps coming up for me that pediatrician and 
psychoanalyst D.W. Winnicott used to describe children who were 
suffering, unfortunately, from the trauma of their parents, and 
he called it that they were suffering primitive agony.
    And, unfortunately, we sometimes have children in 
communities or in the societies in which they belong where 
there are not the protective factors and resilience-building 
conditions for them to heal and ultimately thrive and reach 
their potential.
    I have lived and worked through the impact of the natural 
disaster Katrina that decimated New Orleans in 2005, and, 
unfortunately, some of those effects are still being felt by 
certain communities.
    And now, today, we are on the threat of another flood and I 
know that the people in New Orleans are re-traumatized and are 
triggered.
    The lessons that we have learned from Katrina are very 
applicable to disasters in other places--California, the 
earthquakes, the fires in the West, the tornadoes, the 
blizzards and the snows in the Atlantic and Northeast and any 
other extreme weather event.
    Because, unfortunately for children, it shatters their view 
that the world is safe, and oftentimes it shatters the view 
that the adults can protect them because oftentimes the adults 
themselves become disregulated.
    And when you add that to children who are living in spaces 
with chronic adversities, where they have to deal with the 
impact of violence on a daily basis or being bullied 
excessively or being in foster care systems as was added to the 
conventional ACEs.
    We know that this becomes even more difficult for them. The 
impact of exposure to a natural or technological disasters 
happened in the Gulf can be profound when that is added for 
communities that are under served and living with community 
trauma.
    There is evidence now, as was earlier said, that there are 
these very potentially disabling negative proximal and distal 
physical and mental health outcomes of childhood trauma and 
that it costs so much.
    So what I, as my distinguished colleagues before me have 
said, the Centers for Disease Control, the academic centers who 
are studying this, the professional organizations like the ones 
I belong to--the American Psychiatric Association--we have a 
role to play with those who have the lived experiences of 
trauma, and the community members who need to understand that 
trauma is not normal. In many of our communities--and I have a 
case of a young man who, after he witnessed someone being 
killed in front of him, his mother told him, ``It is okay, 
baby. You will get over it. Don't worry.''
    And so he didn't know that he was going to get worried and 
ended up with a life in prison doing all the things because of 
his disregulation.
    But lucky for him, he found another pathway and is now a 
teacher. And so I think about him and I think about the need 
for us to inform our communities that trauma is not normal, we 
can keep it moving, and that we need then to think about the 
services that we will need when our children have these 
experiences.
    Thank you.
    Chairman Cummings. Thank you very much.
    Mr. Henry?

  STATEMENT OF JAMES HENRY, FORMER DEPUTY GOVERNOR & CHIEF OF 
                   STAFF, STATE OF TENNESSEE

    Mr. Henry. Thank you, Mr. Chairman. It is certainly an 
honor for me to be here today, too.
    Chairman Cummings. Is your mic on?
    Mr. Henry. It is certainly an honor for me to be here today 
and I look forward to my testimony.
    In January 2015, I got a call from the First Lady, and she 
said, ``I want you to go to a meeting in Memphis. They are 
talking about ACEs.''
    And I was the commissioner of the Department of Children's 
Services that I think in most terms would have been called a 
disaster when I went there, and four years later we ended up 
winning ChildHelp award and appearing before this Congress. So 
we made some progress and we are still making progress.
    But I went to that meeting and one of the things you have 
to do as a community before you can get anything done is have 
the right people at the meeting.
    Well, when I got there everybody that was anything in 
Memphis was at that meeting, and I wasn't looking forward to 
the meeting. I didn't think it was going anywhere. I have been 
to a thousand of them, if you know what I mean, and none of 
them mean anything.
    But at that meeting, I heard a presentation by Robert Anda 
about ACEs, and it was so clear to me, even clear to me, a guy 
born in east Tennessee, seventh generation east Tennessean, 
born between the mountains, born in a little town. My mother 
and dad were married for 65 years. I never experienced any 
trauma other than my grandmother getting mad at me a couple of 
times. They helped raise me. My aunt drove, you know, me back 
and forth to school. My other aunt taught school. My uncle ran 
the drug store. There was 50 relatives that helped raise me 
within 25 miles of Madisonville, Tennessee.
    And if you don't think that makes a difference, it does, 
and I realize for the first time that, well, maybe you just 
didn't pull yourself up by the boot straps--you had some help.
    And so as I came back, you know, I began to think about it 
and then when I got promoted to--quickly after that I got 
promoted to chief of staff and took over that, I gave our 
chief, our cabinet, an ACEs test.
    Well, guess how many people had ACEs that were over two? 
Two, out of 22 cabinet members. Well, how do I get across the 
problems that inner city Memphis or Appalachia has with drugs 
and poverty? How do I get that across to people that have never 
experienced it?
    And it is not an easy--it is not an easy task but you can. 
But we--the first thing we did is you have to have the Governor 
involved and they have to have some dollars. We got the 
legislature to approve dollars. We have made it recurring 
dollars. We got into everybody. We went to see the newspapers.
    We did editorial boards just like you do in a campaign, and 
we got them to hold a summit not long after that that brought 
together everybody in Tennessee that was something. The 
congressional offices were recognized and they came, and we 
wanted them to see what would really make a difference in the 
$5 billion deficit in economic development that ACEs was 
costing Tennessee.
    Five billion dollars, because we don't have trained people 
that have trauma, and most of the health care comes from, you 
know, smoking and drug use.
    And, you know, it was amazing to me to see how much 
similarities there were between Memphis and Appalachia, and I 
mean drugs, poverty, not moving forward. It was almost the 
same.
    And, of course, you know, in Oak Ridge, Tennessee, where we 
are lucky to have the highest concentration of doctorate 
degrees in the world, right across the mountain is where we 
have got the most abject poverty in Appalachia. It is even 
worse than the inner cities.
    So we set out to make a difference. We got the 
appropriations. We got people involved. We adopted but we need 
Congress now to help us move forward with this.
    We have got it on such a stage. Forty-two thousand people 
in Tennessee have been trained on this. Six thousand--over 
6,000 teachers, and, you know, we have got 2,000 Baptist 
churches in Tennessee and if all of them would take 
responsibility for one child we could really make a difference.
    We are making a difference in Tennessee. We are going to 
make the next generation much better.
    But Congress, we need your help. We need your help.
    Chairman Cummings. Thank you very much.
    Mr. Patterson?

  STATEMENT OF CHARLES PATTERSON, HEALTH COMMISSIONER, CLARK 
                          COUNTY, OHIO

    Mr. Patterson. Thank you, Chairman Cummings, Ranking Member 
Jordan, members of the committee. I really appreciate you 
taking the time today to talk about this topic because this is 
one of those things in public health that we call a root cause.
    We are trying to figure out why we have had an incredible 
opioid epidemic in Ohio and in Clark County. We are trying to 
figure out, you know, why we can't fill the jobs that we have.
    We have good-paying jobs in our community now. We can't 
fill them. And why can we not fill them? It goes back to the 
ACEs. It goes back to the childhood trauma that we have not 
treated properly, we have not informed our community, and we 
are just figuring that out in Clark County, Ohio.
    We are figuring out that this multi-generational poverty 
that we have is actually multi-generational trauma-driven.
    Because there is a way to get out of poverty. There are 
good jobs. There are--you know, we are not talking minimum wage 
jobs. We are talking about $20 an hour jobs and you don't have 
to have a college degree.
    But we can't put people in them because they don't have 
driver's licenses from the drug use and they can't pass the 
drug test.
    We have got teachers in schools that are trying to teach 
and they are trying to go toward STEM and doing that work. But 
they can't teach the top kids. They can't teach the middle 
kids.
    They are spending their time dealing with the childhood 
trauma. They are dealing with the child that is coming to 
school with all that trauma who is disrupting the classroom.
    And we have always thought that it was because Johnny was a 
bad kid, and now we figured out it is because Johnny has lived 
with stuff that most of us can't even imagine.
    We are seeing it in our court system. Our court system is 
full and our court system is full of folks with mental health 
problems and with opioid problems.
    We review drug deaths for the last several years since 2015 
in our community because we are trying to figure out why. We 
are trying to do, once again, a root cause analysis.
    But when you review a mother's death and then later on you 
review the death of the son, and you wonder could it have been 
ACEs, could it have been the trauma that the child lived with 
the mom going through drug abuse for many years and then 
sitting at the kitchen table doing opioids together.
    It is very sad when we are looking at and we have got the 
data that shows us that we are seeing generation after 
generation.
    So what are we doing locally? We actually have a steering 
committee on trauma. It met yesterday and it has a strategic 
plan. But that plan is basically what the--what the CDC said 
earlier.
    Let us make everyone provide trauma-informed care. So not 
everybody is going to see a doctor. Not everybody is going to 
see a clinician.
    We need everyone in the community to be able to begin to 
build the relationships because the relationships are key and 
that is what--that is where the healing can begin.
    We haven't talked about it enough, and so our community--
you are right. When you said, you know, only a handful out of 
600 people knew about trauma-informed care, we are seeing that 
in our community as well.
    And so we need to get that message out that anybody in this 
room can provide trauma-informed care. You don't have to be a 
medical doctor or a clinician or a psychiatrist. You can begin 
just by building that friendship.
    What do we need the Federal Government to do? What you are 
doing now, is talk about is and come up with a comprehensive 
approach. What we don't need is Department of Education say we 
need to do this and then law enforcement is going to do this 
and the medical community is going to do something else.
    We need it to be a coordinated effort so that they are all 
playing from the same handbook. We need work force development 
because right now, we have open positions for clinicians, 
psychiatrists, psychologists in our community and we can't fill 
them because those people just don't exist. We don't have 
enough of them.
    And the other thing is continue to talk about trauma-
informed care because what we--what we can ask you to do is 
provide hope. There is hope the brain can heal itself and we 
really appreciate your time today.
    Thank you.
    Chairman Cummings. Thank you all very much. I really 
appreciate your testimony. I am going to yield myself a few 
minutes to ask questions, and I just want to let you know that 
I am going to step out for about a half an hour and then I am 
coming back. Maybe a little bit longer.
    But I have got something that I have got to do. I rarely 
miss out on a second of our hearings. It is hard. Sometimes 
they are six, seven hours but I am here. So I don't want you to 
see that as any way disrespectful.
    Now, Mr. Henry, I keep--for some reason I keep going back 
to a question that Congresswoman Pressley asked a little bit 
earlier of the other panel, and she talked about stigma.
    And when I heard you say that you all were able to gather 
everybody in a room, that people who make a difference--I 
assume the people can make decisions, and I guess you are 
talking about the business community too, I guess--how did they 
do that?
    Because you--Mr. Hice and I were just talking about how you 
all have apparently been able to do something to get past this 
thing of, oh, it is their fault, or when you see a child in 
need, there they go again--you know, that kind of thing.
    How do you get past that? And living in the inner city of 
Baltimore myself, going back to something that you said, Mr. 
Patterson, I look at some of the children and I wonder how they 
even get to adulthood, I mean, with all the forces going 
against them.
    So I am just--how did you do that, Mr. Henry?
    Mr. Henry. Well, I think, No. 1 is they have to be aware of 
what is going on. I mean, there is so many people. There are a 
lot of kids involved here and a lot of impact from this.
    But not many people really recognize it. It is a lot like 
dealing with people with disabilities. You know, for a long 
time in this country we didn't realize exactly what we were 
dealing with.
    You know, we did just the opposite of what you ought to do 
with those kind of things. I mean, we hid people with 
disabilities. We segregated them. We did all those things.
    I had a son with disabilities who passed away but--and had 
terrific disabilities but the best thing for him was when he 
got out with people and they treated him normal, and you have 
got to have mentors.
    You have got to have these organizations that are willing 
to step up and you have got to have somebody at the head of it 
that can draw that kind of crowd.
    The Governor of our state took the lead and his wife took 
the lead.
    Chairman Cummings. By leadership.
    Mr. Henry. And there is no--you know, no substitute for 
that. And in Memphis it was A.C. Wharton and, you know, A.C. 
took the lead, and the Pyramid Foundation and, you know, we 
brought all those people together and some of my best friends 
in the legislature.
    I have served as Republican leader for a number of years 
under Governor Alexander--Senator Alexander. And the way we did 
things was that we worked together. I mean, there are very few 
partisan issues when you look at kids, education, these kind of 
things.
    I mean, it is bigger than partisan. So we agreed on those 
things and we used part of that coalition and we still do 
today, I mean, to bring people together and tackle these 
terrible problems.
    I mean, Tennessee has got huge problems. They are one of 
the biggest perpetrator of drugs, you know, alcohol. Smoking 
causes 42 percent of our total health problems.
    Chairman Cummings. Wow.
    Mr. Henry. Smoking. And, you know, and because we have got 
a history of raising it and being it and it was the manly thing 
to do when my dad grew up was to smoke. But he had a heart 
attack when he was 56 years old, you know, and didn't----
    Chairman Cummings. Did he pass?
    Mr. Henry. He survived for another 20 years and then he got 
poisoned working up at Oak Ridge, and thank goodness that the 
Congress appropriated the money in the 1980's to take care of 
some of those folks that died of exposure to radiation.
    But those--it has got to be an all-out effort. It can't be 
four or five people in a state.
    Chairman Cummings. I just have one other question, and that 
is to you, Dr. Bethell. Piggybacking on what Mr. Henry just 
talked about, you said that so often folks are doing things 
that actually are hurting the kids instead of helping them.
    Can you elaborate on that? And he said--I want to hear from 
everybody now. But go ahead.
    Ms. Bethell. Yes. I mean----
    Chairman Cummings. You did say that? And make sure your mic 
is on. Go ahead.
    Ms. Bethell. I did, and I can give you a very concrete 
example on that same----
    Chairman Cummings. Yes, that would be wonderful.
    Ms. Bethell [continuing]. same meeting that I was at a 
month ago where most people didn't know about ACEs. When they 
learned a Title 5 special health need specialist that was going 
into the home to treat a child with autism and noticed that the 
mother was under extreme distress, and also that the child was 
not able to focus by continuing to look at the mother and cry, 
and he wouldn't have gotten paid and he would have been 
reprimanded if he hadn't executed those exercises for autism 
treatment and had no way of addressing the issue because it was 
not in his purview nor did he have any information about the 
other home care visitors and others that were treating the same 
family and neither did the mother know all of the services that 
she was receiving.
    There was no way for them to work together, coordinate, and 
deal with this cross-cutting issue. Probably the traumatization 
to that child by being forced to do exercises that were not 
really what the issue made him feel like he had actually hurt 
those children, and when we talked about this in a later break 
out it went on for a good while what we could do. That is a 
concrete example.
    Chairman Cummings. My mother used to say--my mother used to 
say there is nothing like a person who don't know what they 
don't know.
    Ms. Bethell. That is right.
    Chairman Cummings. And she only had a 4th grade education.
    Ms. Bethell. Yes. But this person knew and couldn't do 
anything.
    Chairman Cummings. And so you got almost the blind----
    Ms. Bethell. That is right.
    Chairman Cummings [continuing]. leading the blind. They are 
not only leading them, they are leading them in the wrong 
direction.
    Ms. Bethell. Right.
    Chairman Cummings. Yes, sir, Mr. Henry?
    Mr. Henry. Just one final thing and I will quit preaching 
to you, Mr. Chairman.
    But, you know, kids are not inadvertently mean. That is a 
learned behavior. And, I mean, if you raise them in the wrong 
environment they are going to turn out unsuccessful most of the 
time, and we see a lot of times where somebody somehow pulls 
themselves up and then you say, well, you can do it if you 
would pull yourself up.
    Well, that is not reality. If you are raised in a bad 
environment you are probably not going to turn out too good.
    If killing and drugs is the norm, that is what you are 
going to, you know, head toward. If not working is the norm, 
that is what you are going to----
    Chairman Cummings. My last question is what--some of you 
have talked about this briefly--but what would you like to see 
us in the Federal Government do to help children?
    I mean, us in Congress.
    Dr. Shervington, did you have something?
    Dr. Shervington. Yes. Government can really assist the 
coordination of these services. Like the gentleman said, we 
don't need the Department of Ed on one said, law enforcement on 
one side. I think we have our public health agency, the Centers 
for Disease Control.
    We have the more clinically oriented services in HHS 
SAMHSA. I think that if those efforts were better coordinated, 
and I am looking to the population level approach to even bring 
SAMHSA in, I think that it would be really helpful to 
communities when we have one message, almost one kind of 
science about how we are going to go ahead and heal.
    Thank you.
    Chairman Cummings. Mr. Patterson?
    Mr. Patterson. Having the hearing today, that is the start, 
right? Talking about it and letting people know that it is out 
there, understanding that it is a root cause and then 
continuing to provide evidence-based programming that folks 
like the CDC present to us so that we can implement it on the 
ground at the local level.
    We don't have the resources at the local level to try 
something that might work. In most cases, we need to put our 
local resources into an evidence-based practice that if we do 
it to fidelity we are going to bet a result.
    And so you can--you can direct your research funding at 
programming that provides that local evidence-based practice.
    Chairman Cummings. Dr. Houry?
    Dr. Houry. I think it is important not to lose sight of 
prevention--really, primary prevention. All too often in the ER 
I would see it. We would see that trauma, and I focus on how do 
I save that life.
    How do I prevent that injury from coming in the first place 
is key, and there are so many ways that can be done through 
early childhood education, promoting social norms, parenting 
skills, really connecting youth to caring adults and we have 
evidence-based programs that do this.
    We need better evaluation of them. I think as Mr. Patterson 
was saying, looking at some of the local innovations, being 
able to evaluate them and scale them up, and CDC is ready and 
poised to really work with Congress on this.
    Chairman Cummings. Mr. Henry?
    Mr. Henry. Mr. Chairman, I would just like to say I think 
the best thing you could do is bring--is what you are doing 
today. And, you know, I think states need to make a commitment. 
The Federal Government doesn't just need to do this.
    If you can't get a commitment from the state to understand 
they have got a problem out there, you are just going to be 
wasting your money.
    But, I mean, these--there ought to be some barometer of how 
a state--how they appeal--I mean, whether a legislature 
understands this issue. Are they willing to appropriate 
recurring money?
    Chairman Cummings. Right.
    Mr. Henry. Not one time.
    Chairman Cummings. Right. Sustained.
    Mr. Henry. But recurring them.
    Chairman Cummings. Yes. Thank you.
    And finally, Dr. Bethell?
    Ms. Bethell. Yes. First of all, there is a way to we need 
to leverage existing programs and policies that are not fully 
implemented or brought to scale including EPST, CAPTA, and many 
of the other programs that serve children already that do not 
integrate this information or are paying and training in ways 
that support their implementation.
    We also, I think, need the Federal Government to take the 
lead in creating a ``through any door'' awareness by being the 
leader like in Tennessee and being relentless in that.
    And then also all of the--all of the NIH programs that 
study any disease practically know that this is a factor but it 
is not included in RFPs as a requirement for measurement.
    We have a lot of things that are and we can start to learn 
more by integrating information about ACEs as well as 
protective factors, positive health, and engagement of 
communities and people, which is essential.
    And finally, to really help the communities that are out 
there that need an emergent process. Even though there is 
evidence-based, the truth is that this has to be tailored to 
the real people in a real community owned by them.
    And so we need common element approaches and supports to 
implement them with data, measurement, tools, and models that 
then can be used by communities where they adapt and make it 
their own because unless we make it our own nothing will 
change. This is relational and engagement-based.
    Chairman Cummings. Thank you very much.
    Mrs. Miller?
    Mrs. Miller. Thank you, Mr. Chairman.
    Oh, my goodness. You all have made my brain go all over the 
place. I certified to teach a long, long time ago. But just due 
to various life experiences I didn't teach. But I volunteered 
in the school system anywhere between 10 and 17 years in some 
fashion.
    And the things that you have talked about--I remember one 
little boy that I had been with on and off for years who played 
ball with my son, and he had terrible life experiences, and he 
had been shot and he--I mean, just many things.
    He made really bad choices, and I can remember one day 
being in the mall and he was hanging out with a group of people 
you wouldn't want him to hang out with, and he saw me and he 
walked away from that group and came up and hugged me and just 
put his head on my shoulder because he knew I loved him and he 
knew I believed in him.
    And I have been involved with the Three Branch Initiatives 
that they have tried. There are so many programs out there that 
you all have touched or been involved with while we are all 
trying to reach those children.
    We have alternative schools in West Virginia that, if you 
talk to the kids, nearly all of them have seen someone in their 
family doing drugs, just like you said.
    But now I will go back to what I was really going to talk 
about. In our committees in previous discussions we have had 
many, many discussions about the opioid epidemic, and I have 
talked about my home state of West Virginia multiple times 
because it is ground zero for this epidemic, as you know.
    We are now seeing second and third generation effects from 
this epidemic--children that are being neonatally exposed to 
drugs. They are in the school system. The principals and the 
teachers are trying to find the correct way to deal with their 
behavior.
    So listening to the things you have to say it is just so 
important. Many children are being raised by other family 
members, grandparents, even great grandparents because Grandma 
is on drugs. It is just--it is happening.
    We have now seen how the environment increases their 
proclivity for behavioral problems and attraction to drugs 
themselves.
    Mr. Henry and Mr. Patterson, you could be my next door 
neighbor--you know, just the experiences you have had, what you 
are doing, the way you talk. We are--in West Virginia, Ohio, 
Kentucky, we all touch--Tennessee--we are all cousins. You 
know, we all touch the same problems.
    And so hearing what you have done in Tennessee sounds 
wonderful and I relate to what you are trying to do in Ohio 
because we have been fighting this in Huntington, West 
Virginia, a long time.
    Dr. Houry, you have been home. You have been where I am. 
Can you discuss how the rise in the opioid epidemic has led to 
an increase in trauma with children?
    Dr. Houry. Absolutely, and I think Huntington has really--
although it has been the epicenter, I think it is really up and 
coming when you look at all of the great----
    Mrs. Miller. Yes. Yes.
    Dr. Houry [continuing]. activities that are going there. I 
left there so impressed and inspired by the work that was being 
done there. There was Lily's Place to where----
    Mrs. Miller. Yes.
    Dr. Houry [continuing]. you saw newborns that were in an 
appropriate comforting environment and parents were taught how 
do you parent.
    You know, how do you really nurture those stable nurturing 
relationships which are the fundamentals to protect against 
child maltreatment and to protect against childhood trauma. So 
I think that is one of the most significant things you can do.
    When you just look at ACEs in general, if you have six or 
more ACEs, it has been shown that men are 46 times more likely 
to inject drugs with that much exposure to trauma.
    And so one of the things that I always say that keeps me up 
at night is we have good treatment for opioids; we don't have 
good treatment for meth and cocaine and these other drug 
epidemics that are coming.
    So if we don't focus on childhood trauma and the exposure 
to substances in the home, we are going to be in a whole lot of 
trouble 20 years from now, 10 years from now.
    And so we have to focus on, again, primary prevention of 
these childhood traumas linked with opioid misuse and we are 
seeing more kids entering foster care as a result of exposure 
to opioids.
    So I think, again, looking at protective factors like 
looking at how do you have youth-linked caring adults. Well, it 
is a Big Brother Big Sister program, After School Matters, the 
programs in Martinsburg.
    I think all those things we can do to put in protective 
supports for kids you are exposed to opioids will really help 
buffer those effects.
    Mrs. Miller. Well, what evidence is available to show the 
role of the faith-based and the family based that can help 
these victims?
    Dr. Houry. So what I would say is it is about that safe 
stable nurturing relationship and it is any caring adult. And 
so there is a program called Powerful Voices really focused on 
women and girls to give them that leadership and that courage 
and that resiliency.
    Faith-based communities are an important partner. I would 
say police are an important partner. Education is an important 
partner. Honestly, we need all sectors to be partners at the 
table.
    And I would defer to my colleagues to really add to that.
    Mrs. Miller. May I have some more time, please?
    Mr. DeSaulnier.
    [Presiding.] If you could. Anyone who wants to address that 
specific issue.
    Ms. Bethell. I just want to say one thing that many might 
not know about. But in the mid-1950's, the Harvard Mastery of 
Stress study asked college students what--how to rate--rate 
their parental caring and worth, and they did a 35-year 
followup study that was published the year before the ACEs 
study was published showing that those that had low ratings 
had--87 percent had illnesses and diseases, many of which was 
addiction, and when they rated it high it was 28 percent.
    And so what we know is it is the absence of the positive 
which we can nurture that really is the buffering and the 
support that we need, so even with ACEs when we have positive 
childhood experiences and warrant the nurturing.
    So any program that can facilitate that we can expect it to 
reduce addiction, which many top NIH NIDA researchers now call 
repetitive compulsive self-soothing, which will occur. The 
nervous system will win, and we need to help people understand 
that they are not bad; they are trying to soothe their nervous 
system and there are other healthy ways to do it.
    Mrs. Miller. One of the things that I have observed in our 
hospitals who are dealing with these precious babies is there 
are cuddling programs where people come in and rock the babies, 
and I made the point to the particular people in the hospital 
it is as important for men to come and rock these babies as it 
is for women, because the babies need the feeling of that man 
holding them close just as much as they do the female.
    It is so important that our children feel that warmth and 
that--just that love that you get from sitting and rocking a 
baby, particularly those that are drug exposed that cry 
incessantly because they--you know, things aren't firing 
exactly right and they don't know what is wrong.
    But, to me, the programs that you all are coming together 
with and the communities that come together it takes us all to 
do this, and I am--I could ask you about the Support Act and 
the opioid epidemics and, you know, are there other ways that 
our administration can help address trauma?
    So do you all have any suggestions of additional things? Do 
you think ACEs is the answer? Are there more things that we 
should work on?
    Mr. DeSaulnier. And I would encourage you to answer that, 
Mrs. Miller. I appreciate your interest and your passion. If we 
get a chance we can come back for more time if you are here. 
But if you could just concisely maybe respond to the 
Congresswoman's comments and questions.
    Mr. Henry. I think there is many things you could do. You 
know, you could visit those places. You can make that a topic 
when you visit.
    You can bring the argument home. You can have hearings on 
it. You know, not necessarily everything comes from money but 
it helps. But, I mean, don't send any money to a place that is 
not committed to solve this problem, and being committed it 
means that everybody is in.
    I mean, the whole future--whatever we are dealing with 
around this world is not as important as this. I can tell you 
the future of America depends on how our children are raised, 
and if we don't make a difference in them then we are going to 
lose all the battles.
    So, I mean, you know, you draw a lot of attention when you 
go somewhere.
    Mr. DeSaulnier. I appreciate that.
    Mr. Henry. And if you were--if you were well versed and, 
you know, just had the training and relayed it to our churches 
across this state--I mean across this country about, you know, 
this is what you can do. Tennessee has 2,000 children in 
custody. There is 2,000 churches in Tennessee.
    Why don't you take one child? I mean, more than just 
Baptist churches. But, I mean, there are places everywhere and 
we are doing a lot of that.
    But there needs to be bigger attention to it and there is 
no bigger chess--I mean, no bigger chess game going on between 
special interests and this because, you know, you are talking 
about drugs and the use of drugs and the--you know, the good 
people and the bad people.
    It is like the old-time preachers and the whiskey dealers 
getting together and being sure that there weren't any license 
put out. But, you know, we need to be sure that we have got all 
these people on the same side.
    I will tell you, if you are out there in the community 
there is nothing more important than this and, I mean, I would 
love to have all the funding you could give. But that 
commitment is what we need more than anything.
    Mr. DeSaulnier. Thank you, Mr. Henry.
    We are going to recognize Ms. Wasserman Schultz for five 
minutes.
    Ms. Wasserman Schultz. Thank you, Mr. Chairman.
    Dr. Bethell, I want to direct my questioning to you but I 
have a sort of a preamble before I ask you the question. You 
mentioned in your opening statement that we need a paradigm 
shifting evolution to address childhood trauma and I have been 
thinking about childhood trauma a lot this week, about the kids 
at the border being traumatized by dehumanizing treatment in 
detention facilities, about the women who experienced sexual 
abuse as children at the hands of Jeffrey Epstein and then had 
their rights violated by our Secretary of Labor Alex Acosta 
denying them any justice or accountability, about the kids in 
Parkland in my home county and around the country whose lives 
have been altered dramatically by senseless acts of gun 
violence, and in addition to everything else, the outrage that 
these are flagrant public health issues.
    These are young people in our country that we are 
categorically failing, and I appreciate so much the courage of 
Ms. Rygg from the first panel when she testified that she felt 
she, quote, ``slipped through all the cracks'' in the agencies 
that are designed to protect children from trauma. Those cracks 
feel like chasms.
    I want to ask about one of the systems that failed Ms. 
Rygg. Approximately 90 percent of children in the juvenile 
justice system have at least two adverse childhood experiences 
and, you know, why do we sanitize all of these terms?
    Adverse childhood experiences is a lot, you know, blunter, 
more rounding the corners way to call the trauma that she 
described what it is. I won't repeat the words, but it is hard 
to feel the same impact that her--like her testimony gave us 
with the term ACE. ACE is benign.
    Nearly half of the girls in the system have five or more 
ACEs. Under the Trump administration, the Office of Juvenile 
Justice and Delinquency and Reform rescinded guidance about 
trauma-informed reforms for girls in the juvenile justice 
system, and OJJDP Administrator Caren Harp said the agency is 
too focused on therapeutic interventions and has questioned the 
validity of neural science regarding adolescent brain 
development science.
    So, Dr. Bethell, why are trauma-informed approaches to 
discipline important? And I will ask Dr. Shervington as well. 
Your organization's Sad Not Bad campaign focused on shifting 
public understanding of the behavior of young people who have 
experienced complex trauma, and if you could describe why that 
is important as well.
    Ms. Bethell. Okay. I will say just a couple things and then 
we can elaborate on it if you would like. But we do things to 
try to help children who we think need our help. But if they 
are not able to be present and in their own body, let us say, 
able to take in information even, they are not able to learn or 
do anything.
    And so what happens under ACEs is we get something that may 
be called developmental trauma disorder, and trauma is as 
trauma does.
    Even if people who don't have ACEs they can have trauma, 
and this leads to disregulation of emotions and body systems 
around stress of any kind where small stresses start to feel 
very big when you have had a history of trauma.
    So even a small request can be difficult to manage and you 
can start to feel the panic and the trauma in your system 
without even knowing that you are--you are not even having any 
thoughts that is happening.
    Ms. Wasserman Schultz. Can I just ask you briefly, do you--
do you agree with Administrator Caren Harp when she says the 
agency is too focused on therapeutic interventions and is there 
any doubt over the validity of neuroscience effect----
    Ms. Bethell. There is no doubt over the validity of 
neuroscience----
    Ms. Wasserman Schultz. Okay.
    Ms. Bethell [continuing]. and also the biologic sciences, 
even in epigenetics now. But if we don't have the environment 
and all the people interacting with the child and not just in a 
therapeutic setting demonstrating the care and understanding 
around trauma-informed practices we can undermine any 
therapeutic approach.
    If you are met in a traumatizing way most of the day, an 
hour of therapy is not going to help you. And so we have to 
have the ``through any door'' and also there is a lot of self-
care and engagement that has to happen.
    So giving somebody a therapy versus engaging them and 
helping them with their own reworking of their nervous system 
and their identity that can be often devastatingly damaged, 
sell a positive sense of identity and the ability to even reach 
out and have positive relationships.
    These are the hallmarks of trauma. So we have to have it be 
where we have relational positive relationships and constant 
affirmations that help us learn how to regulate our emotions 
and bodies and not be constantly triggered by most of what we 
are confronting, especially in the juvenile justice system.
    Ms. Wasserman Schultz. And if Dr. Shervington can respond 
as well.
    Dr. Shervington. Yes. So after Katrina there were no plans 
made for the children, and so what we started seeing in the 
schools was a lot of disregulated behaviors. And so when my 
organization went in, we felt that the little things that we 
were doing as a community-based public health organization 
would not be enough.
    So I was going into the schools. The teachers--and thank 
you for mentioning the importance of teachers--doing 
professional developments for them, having them understand that 
the kids that we use in our public will campaign that they are 
really sad.
    They are emotionally disregulated, which is why we are 
seeing the behaviors, and they are not bad. And when we used 
that language, that hashtag, I think people began to see and I 
think that is what we are all saying, that if you could ever 
understand the suffering that some children are made to 
experience and that they can still get up and go to school, 
that if we could create these safe spaces in the schools, in 
the community, and when needed because they are so damaged they 
have to have the kind of professional help that, together, we 
could all change this problem.
    Mr. DeSaulnier. Thank you.
    Ms. Wasserman Schultz. Mr. Chairman, can I just ask 
unanimous consent to enter this letter into the record from the 
Jewish Federations of North America? They are expressing 
support, addressing the impact of childhood trauma on older 
adults.
    We have 74 million Baby Boomers, many of whom will, 
unfortunately, have experienced trauma in their childhoods, and 
there is a need to conceptualize and address childhood trauma 
as a lifespan issue and create person-centered trauma-informed 
systems of care across health and social service systems for 
children and older adults, and that has never been more urgent 
because of, obviously, the size of the Baby Boom generation.
    So if I could ask unanimous consent to enter that into the 
record.
    Mr. DeSaulnier. Without objection, so ordered.
    Ms. Wasserman Schultz. Thank you. I yield back.
    Mr. DeSaulnier. With that, we will recognize the gentleman 
from Georgia, Mr. Hice.
    Mr. Hice. Thank you very much, and let me begin just--I 
hate that he had to leave early but a big sincere thank you to 
Chairman Cummings--his final words to the first panel, words of 
great heartfelt support and appreciation for them coming 
forward with their stories.
    I think I speak on behalf of both sides of just genuine 
thanks to him and I hope that will be relayed to him.
    Mr. Patterson, let me begin with you. I was extremely 
intrigued with, and think you are spot on with, talking about 
how trauma is a root cause of so many other issues, and you 
mentioned poverty itself being trauma driven.
    I am just curious, now that we are seeing record low 
unemployment and so many different positive results in that 
regard if having a dignified stable job in and of itself can 
help either prevent trauma or promote healing.
    Mr. Patterson. Well, sir, you are exactly right. It is one 
of those supporting factors that we need as an adult to deal 
with the situations that we have had.
    Unfortunately, we are unable to get a lot of those people 
into the work force because of very high ACE scores so that--
and, you know, directly we are talking about way too much 
trauma to be able to not be involved in drugs.
    The employers--many employers still have to have--for their 
workers compensation they have got to have a drug test on file. 
They have got to have a driver's license to get back and forth 
to work.
    Where we live we don't have a massive transportation 
system. So you pretty much have to have a car to get to work. 
So the jobs are there and it is certainly a supporting factor.
    But we need to be working early--I agree with Dr. Houry we 
have got to do prevention work so that we don't have to deal 
with it.
    But for those traumas that have already occurred, we have 
got to do work early and often because the earlier we begin to 
intervene the better the results of the therapy is. So you are 
absolutely right.
    Mr. Hice. That does----
    Mr. Patterson. A job--a job helps. But if you can't get the 
job----
    Mr. Hice. Exactly, and it is not a cure-all. I mean, all of 
you, you have spoken of family and faith and community and a 
host of other factors that are all involved and necessary, and 
again, just--I won't have time to get to all of you but thank 
each of you for the roles that you have in addressing this 
issue.
    Dr. Houry, let me ask you, and this is--dealing with 
Generation Z there was a recent--in the age 15 to 21-ish, 
somewhere in that ballpark--I saw a recent survey that said 
that this particular generation lives with constant fear and 
anxiety since Donald Trump's Presidential election. That is one 
thing.
    My question is does CDC fall into that type of anxiety as 
being trauma? Seems like we are talking two pretty diverse 
emotional experiences here.
    Dr. Houry. When we are looking at adverse childhood 
experiences it is things like, you know, child abuse or 
something you witness in the home. So that is how we define 
trauma.
    Mr. Hice. Okay. So stress in this regard anxiety would not 
fall under trauma?
    Dr. Houry. I think if you look at what childhood trauma in 
itself is if something does engender stress that could have a 
physiological or physical or mental health reaction then you 
could say that it would be a trauma. But it wouldn't fit into 
one of the----
    Mr. Hice. Not to the same extent. Okay. All right.
    Yes, ma'am?
    Ms. Bethell. I just wanted to say that, you know, we want 
to address ACEs because we would like to promote flourishing, 
which has to do with having a sense of meaning and engagement 
in life and having hope and optimism.
    So anything that detracts from our ability to have a sense 
of hope and optimism in our lives and the ability to move 
forward and contribute in ways we think are valuable will 
diminish flourishing.
    And for people with trauma, which is about half of U.S. 
children to on top of that start to live in a world where they 
think their opportunities are not there and that they can't 
quite figure out what the point is anyway, which is the bulk of 
the friends of my nephew who is in that age bracket, that they 
can't figure out what there is to live for a lot of them.
    And this is not a small number. So we do need to lift up a 
sense of meaning and hope and optimism as a way to prevent even 
future ACEs even for kids who don't have them today.
    Mr. Hice. No question.
    Ms. Bethell. I think it is important.
    Mr. Hice. No question about that. I have probably a 10-
second--while I have got you probably a 10-second or less 
answer. You mentioned in your opening statement about illnesses 
that actually come from unaddressed trauma and that caught my 
attention.
    Can you give an example or, like, what kind of illness?
    Ms. Bethell. Yes. I mean, there is a book called ``The 
Autoimmunity Cure,'' which documents in very clear scientific 
manner the way that the toxic stress from ACEs and childhood 
trauma directly impacts inflammation in the body and how that 
goes throughout all of the body systems.
    There is a book coming out called ``The Angel and the 
Assassin'' soon that is examining the power of the microglial 
cell as an explanation for the brain pruning under stress that 
leads to mental illness.
    And so we have very strong ways that we know that toxic 
stress gets embedded in the body and outpictures in autoimmune 
conditions inflammation and mental illness. This is very 
important that we understand how we function biologically based 
on our relational and lived experiences.
    Mr. Hice. Another example of root cause.
    Thank you very much.
    Mr. DeSaulnier. Thank you, Mr. Hice.
    I am going to just remind members, we have members--we 
would all like to spend more time on this issue and I would 
suggest that we need to.
    But we have got members who have commitments at other 
committees who are trying to manage their schedules. So I am 
going to keep people to the five-minutes. And this is not an 
admonition to the next speaker.
    Ms. Ocasio-Cortez, you have--recognized for five minutes.
    Ms. Ocasio-Cortez. Thank you so much, Mr. Chair. Thank you 
to all of our witnesses both in our first panel and to you all 
right now for coming.
    I think, as was echoed earlier on both sides of the aisle, 
this is one of the more powerful and one of the most powerful 
and brave hearings that we have had in a very long time and I 
think there is a reason for that, not only due to the expertise 
and the courage of our witnesses but thanks to the tireless 
work of our chairman and the work of Congresswoman Ayanna 
Pressley.
    This is our first hearing on childhood trauma in the 
history of the Oversight Committee, and I just want to commend 
her and to commend our chairman for having the foresight and 
seeing that this is a macro issue of national consequence.
    Dr. Bethell, was I correct in hearing you say that half of 
children have some form of childhood trauma?
    Ms. Bethell. Yes. So using the CDC's definition and 
adapting it for--as appropriate for the National Survey of 
Children's Health, which we have an entire paper on if you want 
to read about it, we estimate that about half----
    Ms. Ocasio-Cortez. Half?
    Ms. Bethell [continuing]. almost 47 percent of children 
have exposure to one or more ACEs. And, of course, there is 
things that aren't measured in there, but because they are very 
co-occurring we don't expect that we are missing children 
overall.
    Ms. Ocasio-Cortez. Half?
    Ms. Bethell. Yes, half, and that most of our children who 
are bullied, who have special health care needs, 70 percent who 
have an emotional mental behavioral condition that we also 
identify have ACEs. So it is half. But for the systems that we 
serve children in through Federal programs, most have ACEs.
    Ms. Ocasio-Cortez. Yes. And I think it is important that we 
note for the record and for all people that childhood trauma, 
as was noted by my colleague earlier, is a lifelong issue for 
people to live with and deal with, which means at some point in 
this country at least half of an entire generation will be 
dealing with trauma.
    And when I think about this on a macro level, we think 
about how intergenerational trauma is not just familial but it 
is cultural. Right now when we talk and what was alluded to 
earlier, when we think about the childhood trauma induced by 
the opioid epidemic.
    Dr. Shervington, I have to thank you so much for pointing 
out specifically the role of natural disasters informing 
childhood traumas--Hurricane Katrina, Hurricane Maria.
    We are already seeing children in schools in Puerto Rico 
exhibit signs of post-traumatic stress. Child separation at the 
border, the traumatic impacts of poverty alone, post-traumatic 
stress, domestic abuse--this is half of our country. Half of 
our country's children.
    And so the health of our children is reflection of the 
health of our Nation, and how we are going to have to deal with 
these traumas is a collective responsibility on the public 
policy across all of our issues, whether it is homelessness, 
immigration, what have you.
    Dr. Shervington, how does--you know, I want to zoom in on 
an issue that, as I mentioned, you highlighted--the effect of 
climate change and natural disasters on childhood trauma.
    Can you highlight how does a hurricane like Katrina or 
Maria, particularly one that has caused a lot of destruction, 
affect a child's mental health as they approach adulthood?
    Dr. Shervington. Yes. Children need two things: to have 
caretakers who make them feel safe and to continue to feel that 
the environment in which they also live is safe.
    When Hurricane Katrina happened in New Orleans, all of that 
was shattered for the children and, likewise, I know, in Puerto 
Rico and some of the other natural environments that happened 
all around.
    Unfortunately, what--children are in a, like, double whammy 
because usually they don't have the language to talk about how 
they are feeling and oftentimes the adults they are dependent 
on they are disregulated. They are just trying to figure out 
how to cope.
    Many families in New Orleans talked about, and in 
particular, say, mothers who are breastfeeding, that it was 
very hard for them to connect with their child that usual 
loving warm affectionate bond that children need--that they 
weren't capable of doing that.
    We even had some kids that we have identified there, and 
there is some science done by Dr. Yehuda, of what happens with 
mothers who are experiencing a trauma such as a natural 
disaster and how that gets transmitted in utero to the kids.
    So a couple years ago I was asked to deal with some kids 
who were just being born during Katrina and they were extremely 
disregulated. The principal had enough wherewithal to know 
there is something going on there.
    So we have to remember that when a natural disaster happens 
and, in particular, where we have communities where the 
families are just barely making it--they are on the edge--so 
they don't have the comfort of thinking oh, my insurance 
company is going to take care of this--that it really 
complicates and makes more complex what would naturally happen 
like we saw in New York. A lot of families came back. There was 
so much support.
    We are still reeling from that in New Orleans and I am sure 
in Puerto Rico where we did not get the amount of psychosocial 
and financial supports.
    Ms. Ocasio-Cortez. Thank you.
    Mr. DeSaulnier. Thank you.
    The chair now recognizes the gentleman from Wisconsin, Mr. 
Grothman, for five minutes.
    Mr. Grothman. Yes. A very interesting hearing. I would like 
to thank you all for being here.
    Percentage wise, say, of people high school age in this 
country--I don't know whether I will start with Ms.--Dr. 
Shervington or Dr. Bethell--how many people do you think should 
come in contact with a professional in this country to deal 
with their potential problems?
    Dr. Shervington. I think that what we need to do is make 
families----
    Mr. Grothman. No. No. I wanted kind of a number, like 
percentage wise how many, say, Americans high school age--say, 
14 to 18--you think should be coming into contact with a 
professional.
    Ms. Bethell. When we look at the data for youth who are in 
school who have two or more ACEs and the high prevalence of any 
number of conditions that they have, that is about 28 percent 
of all children age 12 to 17 and much, much higher for certain 
subgroups according to income and race/ethnicity.
    So it is a large group. But about one in four children in 
the country.
    Mr. Grothman. Is that 28 percent for anything under the sun 
or 28--because I am sure there are problems people have in 
addition to----
    Ms. Bethell. Twenty-eight percent have the exposure of two 
or more ACEs where we see high rate--much higher rates of 
special health care needs, emotional mental behavioral 
problems, and lack of engagement of school at very high rates 
at that level--almost more than half.
    So and in certain populations it is much higher. So I am 
estimating that about 28 percent of youth 12 to 17 need some 
kind of special intervention probably right now.
    Mr. Grothman. By a professional?
    Ms. Bethell. Yes.
    Mr. Grothman. Okay. And how many--how many do you think are 
getting help?
    Ms. Bethell. Well, we know something from the National 
Survey of Children's Health that less than half of children who 
we already think need that kind of service, which means we are 
already diagnosing them, which we often don't find, are not 
getting the mental health and treatment services that they 
need.
    So my guess is that when you also add in those who are at 
risk that it is probably upwards of 60 to 70 percent.
    Mr. Grothman. Let us talk to somewhere numbers that are 
harder--you know, more hard numbers to get at. Do we have 
numbers like over the last 50 years, say, the number of 
children who commit suicide or attempt suicide?
    Ms. Bethell. We do have that data, actually. It is, of 
course, measured in the national vital and health statistics, 
and for youth 15 to, I think, 23 suicide is the number-one 
cause of death.
    Mr. Grothman. Can you tell me where it is, say, today 
compared to 20 years ago or compared to 40 years ago? I guess 
that is what I am looking for, you know, for some time 
comparisons.
    Ms. Bethell. Yes. Dr. Shervington may know more, but I do 
know that it has increased and I would be happy to followup 
with giving you very specific numbers on that.
    Mr. Grothman. Dramatically increased, all of the----
    Ms. Bethell. Suicide rates have dramatically increased 
across the board. Actually, they are high for also middle aged 
adults and are dying from the diseases of despair generally in 
this country with higher death rates than most other developed 
countries.
    So suicide has become an epidemic that is characteristic of 
our generation.
    Mr. Grothman. Dramatically increased?
    Ms. Bethell. Yes.
    Mr. Grothman. Okay. Do you know the percentage of the 
population on medications designed to deal with depression or 
to try to push of suicide? Do we know the percentage of the 
population both kind of in the youth population, the high 
school years, and the adult population as a whole? Do we know 
what those numbers are?
    Ms. Bethell. I don't have all those numbers but we do 
collect data on the proportion of children, say, with ADHD and 
depression who receive medications, and once they are in 
treatment, which is a whole another thing of getting into 
treatment, the top priority treatment is medication.
    However, many of the symptoms overlay with trauma. So one 
of the movements we would like to see is that before we 
medicate our kids and put the numbers of kids on foster care on 
Abilify, which generally can prevent them from even engaging in 
school, first we need to assess and treat the trauma, and if we 
do use medications to use them in a complementary way because 
there are so many needs and opportunities to help deal with the 
symptoms of mental health rather than treat and just medicate 
them.
    Mr. Grothman. What I would like, because, you know, in 
analyzing this problem it is nice to see over time what we are 
doing and how things are changing over time, is the number of, 
I suppose, both adults but and particularly children, say, high 
school to college years, say, 14 to 22, committing suicide, 
attempting suicide, and people taking legalized drugs for 
depression or that sort of thing, and perhaps the number of 
professionals out there over the last 50 years so we can kind 
of get a handle on what we are doing and----
    Ms. Bethell. I am going to defer to Dr. Houry on some of 
that from the Youth Risk Behavior Surveillance Survey. But I do 
know that about half of youth say that they have thought 
about----
    Mr. DeSaulnier. Dr. Houry, we will let you----
    Mr. Grothman. Okay. Well, she has got an assignment, thanks 
to--Dr. Bethell has given you an assignment.
    [Laughter.]
    Dr. Houry. Happy to do it.
    Mr. DeSaulnier. And we are going to allow you to complete 
that assignment as long as it is done in a timely fashion.
    Dr. Houry. Got it.
    So we released the vital signs this past year on suicide in 
the United States and saw that in 49 of the 50 states suicide 
rates went up in the past 20 years. More than half the states 
went up 30 percent, so significant rates.
    We are seeing it going up highest in middle aged adults but 
we are seeing it go up in youth as well and we have completed 
several outbreak investigations of youth suicides in the United 
States, most recently in Stark County, Ohio, where we saw that 
youth that had three or more adverse childhood experiences 30 
percent of them disclosed suicidal ideations, and if they also 
had said they were using opioids plus had those adverse 
childhood experiences 80 percent disclosed suicidal ideation.
    I want to just say one thing, though, about the 
medications. I think it is important to realize suicide is not 
just about mental illness.
    More than half the people who died by suicide did not have 
a diagnosed mental illness. Oftentimes, it is precipitated by a 
traumatic event--loss of a job, partnership issues, economic 
issues. So it is not just mental illness, which is why, I 
think, resiliency is so key.
    Mr. DeSaulnier. Thank you.
    The chair recognizes the gentleman from Maryland, Mr. 
Sarbanes, for five minutes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    I want to thank the panel. I apologize. I have not been 
here for a lot of this testimony. I was here for the earlier 
panel, which was a very powerful one.
    It was occurring to me as we were hearing from the earlier 
panel that the--this trauma, trauma gets delivered in a lot of 
different ways and what I mean by that is there is these, in a 
sense, collective events of trauma like a mass shooting or the 
effect of a natural disaster. Then there is trauma that is 
delivered in a very kind of specific and often hidden way.
    And the response to those, I guess, professionally and 
clinically may be different. But I wondered if you could speak 
to--and if this is has come up already again I apologize--but I 
wonder if you could speak to how critical--I have just come 
from a hearing in the Energy and Commerce Committee where we 
are re-authorizing community health centers, and many of them 
are connected to school-based health centers.
    And I have been an advocate for a long time trying to 
strengthen school-based health centers and really aspire to 
where every school has a health suite that is there at every 
level--elementary, middle, and high school--and then making 
sure that among the professionals that are serving those 
centers are mental health professionals and counselors and so 
forth.
    I can't think of--maybe you can--but I can't think of a 
better place to bring those services to address many of the 
trauma situations that we have discussed today than into our 
schools, because you have a captive audience.
    You have the audience that is the most impacted at a young 
age from trauma whether it is something that has been 
experienced at home, whether it is one of these collective 
impacts, et cetera.
    Could you just speak to the value of school-based health 
centers, how we can make them more robust in terms of the 
mental health component and if you view that as a place where 
we can make tremendous progress in terms of addressing 
childhood trauma?
    And it is open to anybody on the panel who would like to 
address the topic.
    Mr. Patterson. Well, I would like----
    Dr. Shervington. I just----
    Mr. Patterson. Go ahead.
    Dr. Shervington. As what I would like to consider myself a 
community psychiatrist who is on the ground with our people 
after disaster and just people who have lived chronically 
through trauma that schools are one of the most protective 
places if we can make them that for children.
    A lot of traumas happen in the home. We have situations, 
say, for example, where a kid is being exposed to domestic 
violence. The police comes, take a parent--whomever was the 
perpetrator.
    One goes to the hospital, one goes to jail, and you know 
where the kid goes? To school. And that kid in school is not 
going to be able to concentrate and work that day.
    So I strongly support and beg for us seeing schools as 
having health centers that can respond to their needs--social 
workers and also doctors are important in that, too.
    And, again, having schools--the climate in the schools 
being trauma-informed. If we could do that, we would go a long 
way. Many stories of survival I hear from adults when they look 
back it was a teacher. A teacher saw something. A teacher did 
something. So I just want to say how important health services 
in the schools are.
    Mr. Patterson. The federally qualified health center in 
Clark County is a comprehensive medical home, and so we have 
already heard about how the mental health issues and the trauma 
affects long term the health of the children.
    And so we take this federally qualified health center that 
is a wraparound service for the children and their families and 
then we extend it into the schools, which means the captive 
audience that you are talking about, right, and then we have 
comprehensive mental behavioral physical health all in one, not 
just for the children but for their families as well, and the 
school is a walkable place for most of our communities.
    And so then you have the ability for this all to happen in 
one place. It is a perfect fix. It doesn't fix everything 
because we have to train the entire community to be trauma 
informed. But if we are able to expand that into the schools, 
it really is a no-brainer.
    Ms. Bethell. I would just like to say a few more things.
    One is that you mentioned acute stresses. But chronic daily 
stress, actually, in the literature has been shown to be even 
more impactful over life, especially when the acute stressors 
are often--more often addressed because they are more obvious.
    So it is very important to know that, and also for schools 
that don't eliminate expulsion that, you know, when children 
act out it is very important that we consider not no expulsion 
from school but instead dealing with trauma, and that the first 
response is not reporting to child welfare because often the 
issues can be found earlier and if teachers' only response is 
to be a first reporter, then they may not want to say anything 
because they don't want to destroy the family.
    And so we need a lot of ways to support children and 
families without expelling children from school and without 
reporting families to child welfare first.
    Mr. DeSaulnier. Thank you.
    The chair recognizes the gentleman from Pennsylvania, Mr. 
Keller, for his first questions on this committee. And we are 
not always this bipartisan. Hopefully, this is--you are going 
to change things.
    Mr. Keller. I hope to be able to do that.
    Thank you, Mr. Chair, and I want to thank the panel and 
also the panel this morning. You know, it is hard--you can't 
even imagine people that have suffered the things that have 
happened to the people here today and people--are continuing to 
happen around our Nation. It is--it is tragic.
    And I just heard a couple things that I want to make sure I 
understand and it dealt with some of the issues with ACEs and I 
heard poverty mentioned quite a few times, and just--and Dr. 
Bethell, I read through the graphs that you had and it seemed 
that in cases of poverty, if I understood what we were given, 
that the ACEs tend to be higher for, I will say, kids and young 
adults that live in poverty.
    Is my understanding correct from the information?
    Ms. Bethell. Yes. The information I gave you was for those 
for 200 percent or below the Federal poverty level, which is 43 
percent of children. They represent 57 percent of children with 
ACEs.
    Mr. Keller. And then as you saw the income increased then a 
decline in the ACEs?
    Ms. Bethell. Yes, except for it is still very high in all 
income groups. And I will say that it is very agnostic 
according to income once experienced in terms of the effects on 
health.
    Mr. Keller. Okay. The other thing you mentioned during--I 
think it was Mr. Hice was asking some questions--you mentioned 
about young adults a sense of purpose and being able--you know, 
that is creating some issues too with young adults. Is my 
understanding of that correct, too?
    Ms. Bethell. Yes. We just published a paper in Health 
Affairs about a child flourishing, one of which is whether 
children are curious and interested in learning, able to devise 
and fulfill tasks and goals that they have and remain calm and 
in control when faced with a challenge, and only about 40 
percent of school-aged children in the country meet all three 
of those criteria.
    So we need to proactively promote flourishing to help 
children grow into adults that can have a sense of meaning, 
purpose, positive relationships, hope, and optimism, and that 
is a cross-cutting need regardless of ACEs.
    Mr. Keller. Yes, I would--I would agree and, you know, 
there is also a study from the ``Early Childhood Poverty and 
Adult Attainment Behavior and Health.''
    University of Chicago did a report that showed that when 
there is an increase in income that helps the children's future 
income increase--a modest increase in income helps a 
children's--or a child's income later on increase by 17 
percent, which I think would help some of those issues, 
particularly for the kids in poverty.
    Ms. Bethell. Absolutely.
    Mr. Keller. Is that--is that something you are familiar 
with and do you agree that that might be helpful?
    Ms. Bethell. Well, the literature is pretty clear about 
that. There is a lot of co-occurring issues for children in 
poverty, and so when you parse them out it can be difficult to 
isolate. Is it the income? Is it the things that the--you know, 
other things that have gone on?
    But a researcher, Renee Joynton Barrett, has researched a 
lot how there is mobility in poverty and often dealing with the 
issues of trauma that are intergenerational can help families 
actually move out of poverty and take advantage of the supports 
that are available to them.
    We do have an issue of getting people to take advantage of 
supports that are offered because one of the things trauma does 
is it can stall the self-care instinct and the ability to 
actually activate the will to be well.
    And so we offer things and then they don't necessarily able 
to follow through and use the resources. So I think hand in 
hand we have to deal with the trauma of poverty and the trauma 
of ACEs simultaneously.
    Mr. Keller. I think, you know, there is a lot of value in 
making sure that people have more income and more money to take 
care of the needs they have which, you know--you know, getting 
back to that, that small increase in 2017--end of 2017 the tax 
cut, you know, was passed and more families, according to the 
Tax Policy Center, you know, are keeping $1,600 more a year or 
getting $1,600 more a year back in their income taxes, which I 
think has to be a benefit to some of the poor families to be 
able to take care of themselves and have some more of those--
help them create more of a sense of a worth because they have 
more control over what is happening in their lives.
    So I guess I would--I would just say I think that is a 
positive impact, the fact that President Trump got that through 
Congress and people are keeping more of the money they earn. So 
that should be helpful.
    I would say are there other things that we could do or 
policies that we could enact that would help people be able to 
direct more of their own--their own resources, that give them 
more sense of worth rather than, you know, just--I think it 
takes everything.
    I think there is a lot of things we talked about but what 
other things--you know, should we make those tax cuts 
permanent? What kind of things should we do to have an 
ongoing--an ongoing success of people coming out of poverty?
    Mr. Patterson. Anything that we can do to build resiliency 
in our children to be able to handle the adverse childhood 
experiences that they have is going to be positive.
    And so if we are able to put prevention programs in place, 
if we are able to--you know, a rising tide does float all 
boats. But your boat--if your boat has holes in it, it is going 
to be pretty tough for that to take effect.
    So we need to help the people patch up the holes so that 
that rising tide can help everyone.
    Dr. Houry. I would just add we have technical packages on a 
lot of our violence prevention strategies and economic supports 
is one of the pillars. Things like earned income tax credit, 
child care subsidies, have been shown to reduce child 
maltreatment or associations with it.
    Mr. Keller. So that, coupled with tax savings, are a 
positive things for our families and for people in poverty.
    Mr. DeSaulnier. Thank you. I want to thank the gentleman. 
His time is up.
    Ms. Bethell. I would say if they are working then they can 
benefit from that. But having a living wage and being able to 
actually manage to where you even earn enough to have much 
taxes taken out I think is probably preliminary even for many 
of the families we are discussing.
    Mr. DeSaulnier. Thank you, Doctor.
    Now the chair now wants to recognize the Congresswoman from 
Massachusetts and also acknowledge her leadership on this 
issue.
    Ms. Pressley, your five minutes.
    Ms. Pressley. Thank you.
    I did want to also just thank Representative Sarbanes for 
his leadership and partnership on the issue of school-based 
health centers. There but for the grace of God go I.
    I can say with certainty that it was a school nurse that 
saw the signs of trauma and abuse in my own life, and it is so 
important that the school community are trained in these 
indicators, because, yes, there are children that act out but 
there are many more that shut down, and I was one of those 
children.
    I do want to say, though, I have always taken issue with 
the term that children are resilient because I think it infers 
for people that they get over things. And the reality is that 
no child, no person, is really that resilient.
    What we are is delayed, and these things do all show up in 
some way, form, or shape in our lives. It presents differently 
for everyone, and I think ultimately what we want to see in our 
school communities is a paradigm shift in culture where people 
will ask, what happened to you, instead of, what is wrong with 
you, and that is a distinctive shift that needs to occur.
    But it is also important to note that our children are not 
independent contractors. You know, they are part of a broader 
ecosystem of family and community, and the best gift that we 
can give any child is a stable adult. But most adults are also 
destabilized, right.
    And so when you talk about the issue of trauma and the 
stigma and the stereotyping and the one-dimensional narrative, 
I want to say when I first started talking about this issue in 
running for the Boston City Council that people were worried 
that I was coddling children or that I was feeding a stereotype 
of who is impacted by trauma.
    And that is why the testimony of our witnesses earlier is 
so important and what you have offered her today is that 
hardship and trauma do not discriminate. There are some 
disruptions and hardships that are disproportionately bore by 
others based on historical legacies and systems and structures.
    But it does not discriminate. And so bearing that in mind, 
this is a public health issue, an epidemic, and it must be 
treated as such. And we need to be not only coordinated but 
equitable.
    There is no hierarchy of hurt, and I appreciate you are 
pushing for us to address this in a comprehensive way. I 
convened the first hearing in the Boston City Council, a 
listening-only hearing to hear from 300-plus families who are 
survivors of homicide victims, and that was where it was 
underscored for me that it is critical that this work be 
survivor-led.
    My district is coming off of the heels since July 3d of 18 
shootings, and so I recently convened and assembled civic 
leaders, faith leaders, survivors, advocates, family members of 
offenders, to all come together.
    And so I request unanimous consent to enter into the record 
written testimony from the Office of Suffolk County District 
Attorney Rachael Rollins, the Louis D. Brown Peace Institute, 
which has an incredible national model and blueprint for this 
work, Wellspring Mentors, Mass General Hospital, and residents 
and community leaders across the Massachusetts 7th.
    Ms. Pressley. Picking up on that note of the need for us to 
be coordinated, there were medical professionals that were in 
this meeting and they said that they have been trained to 
stitch up victims, and many of them were repeat victims.
    But it was only recently they thought to ask about who are 
they and what are the needs of those victims that were coming 
in to their ER and they were stitching up and why is that they 
keep coming back, right.
    So I just wanted to lift up something from the 
Administration for Children and Families. It says African-
Americans experience generations of slavery, segregation, and 
institutionalized racism that has contributed to the physical, 
psychological, and spiritual trauma.
    Dr. Shervington, when the root causes that often lead to 
trauma are so entrenched in our very infrastructure--
discriminatory housing, policies, health and racial 
disparities--how do we respond?
    Dr. Shervington. I think, as you said, a real comprehensive 
approach. I tend to see these issues across the social 
ecological models. So as a physician, as a psychiatrist, at the 
individual level when the harm is done we need to fix that for 
the person.
    And I would just like to underscore what you said. How many 
times can you kick someone down and expect them to get back up? 
And usually it is in those systems and those structures.
    And so as public health practitioners or clinicians, we 
have to advocate for those kinds of policies that are going to 
look at those inequities and try to fix them.
    We can't do them alone and so we have to be in partnership 
with those in our communities and it has to be community driven 
how these inequities play out.
    We have to work with them. We are not isolated. So in our 
emergency room in New Orleans--the public emergency room--there 
are trauma surgeons.
    They have this--they have built in some supports where at 
least they are screening for PTSD in the victims who are coming 
in, or I should say survivors. They are working with them.
    But they are also going into the community, working with 
community-based advocates who are really looking at these 
structural factors that help to perpetuate the poverty and the 
violence that can happen when communities are disconnected.
    Ms. Pressley. Thank you.
    Mr. Cooper.
    [Presiding.] Thank you. Your time has expired and Mr. 
Gibson is recognized for five minutes.
    Mr. Gibbs. Gibbs. Thank you.
    Mr. Cooper. Gibbs. Excuse me. Of Ohio.
    Mr. Gibbs. Thank you, Chairman.
    First of all, I want to associate myself with Chairman 
Cummings' closing remarks on the first panel. And I see some of 
the witnesses are still here and you really are heroes for what 
you are doing, and God bless you.
    You know, sitting through listening to all of this it has 
been interesting and very educational for me. But I think about 
the trauma it causes, you know, from a couple categories--
poverty, abuse, drugs. I think we are all in agreement on that.
    So I just want to be clear because it came up in an earlier 
question. In the--in the tax bill that we passed here in late 
December 17 we did put a--we doubled the child tax 
credit from $1,000 to $2,000.
    But even if you don't owe any taxes--a family doesn't owe 
any taxes there is a refundable tax credit of $1,400 per child 
for their dependent children, and they just need to file, I 
guess. So that is important to help on the poverty side, even 
if they aren't working. Just want to make that clear.
    What I want to followup a little bit on is--and Mr. Henry 
and Mr. Patterson, and welcome from Ohio, too, and I know 
Springfield. You know, I live about two hours from there.
    But just to followup, talking about coordination and I know 
Mr. Henry talked about more money is always nice but then we 
got to make sure that the local people or entities are 
committed and but then this coordination thing.
    And I just got a couple of examples. I know we have the WIC 
program--the Women, Infants, and Children program under USDA--
and those social workers go out to those lower income families 
after a child is born and help with those nutrition needs.
    As an example, if they see something as their followup, 
like if Mr. Patterson had been the health commissioner there in 
Clark County in Springfield, Ohio, what kind of followup 
coordination?
    And then I guess another example would be all my children 
are now in their 30's. They are all grown up, and I remember 
one time when my oldest child broke his arm and we went to the 
emergency room about--at 9 o'clock at night, and I felt like I 
was on the 5th degree--you know, the questions--questions to 
make sure it wasn't child abuse.
    And so I just want to see if we are not in silos, what kind 
of followup, and then also followup with a faith-based 
community, you know, if it is needed because I think there is a 
lot of good things.
    I know Mr. Henry has talked about if one church stood up 
one child it would make a big difference and we know one person 
can make a big difference.
    And so what I am trying to say is with the coordination we 
have is there something more that we could do at the Federal 
level to help with that coordination?
    So I will just open it up to you two gentlemen since you 
have got the experience. Go ahead.
    Mr. Patterson. What I would first say is that the WIC 
program model in Ohio is typically that the families come to 
us, and so sometimes we see things and then as mandated 
reporters we do what we need to do.
    We are lucky in Clark County that our WIC division and our 
early childhood divisions are co-located, and so if there is an 
issue they can literally walk the people down the hall and do a 
warm hand-off to make sure that there is followup there. So 
that can happen pretty easily.
    The issue, you know, in that case really becomes we are not 
seeing them in their homes and that is why we have an early 
childhood division that does home visiting, which is in fact 
funded by you and that is a major impact for us to be able to 
go in.
    We know--the research tells us that us being in the home 
actually prevents child abuse. It doesn't prevent all of it but 
it reduces the incidence of child abuse because we are in the 
home. And so we continue to do that to work with the families 
and build the programming so that they can be successful and we 
do have the relationship.
    We have talked several times--you have heard today about 
one of the ways that you deal with trauma is you have a caring 
adult, you have a relationship with someone, and that is what 
that home visiting program actually does is provides a caring 
adult who gets to know the family, the family gets to know 
them, they build a trust, they build a relationship, they build 
accountability, and they build a plan on where they are going 
in the future.
    Mr. Gibbs. How is your relationship--I know you are semi-
rural. Kind of you are a rural county but you got Springfield, 
not a large city, with a faith-based community involvement and 
try to--and try to----
    Mr. Patterson. Our faith-based community is involved in 
lots of ways. One of the things they are doing is they help 
supplement where the programs can't purchase certain items for 
the families either for comfort or for safety.
    Our faith-based communities are contributing that to our 
programming. But they are also beginning to work more with our 
community health improvement plan and being involved in the 
results.
    So they are actually from the pulpit sending the messages 
about health, about trauma, about mental health, about opioids, 
and that is making a big difference.
    Mr. Gibbs. I have seen it in my stakeholder meetings, 
especially on the opioid crisis. The faith-based community 
definitely has a role to play and in partnership with all the 
other stakeholders, and that is--I think we are trying to--I 
think in Ohio in the opioid issue we are starting to turn the 
corner on the aspect of awareness and education.
    You first got to be aware of the problem and recognize the 
problem and I think we have turned the corner with that aspect, 
even though we still have a crisis. Don't get me wrong.
    So go ahead.
    Ms. Bethell. Yes, I just wanted to speak to this, and I 
think it really relates to what you are saying about faith-
based organizations and the role they can play, which is we 
really don't ask families themselves to reflect on what their 
assets and needs and their current concerns are, and to set 
their agenda for the priorities and the things they think they 
need help with that can then be shared with a wide array of 
professionals that help them.
    So that we base what we are doing on the needs of the 
family and also support them in a reflective process to start 
to see what are the things that they have as strengths but also 
the things they need help with, and we can do a lot of 
standardized screening to bring it right to the table so we 
don't spend all of our time and all of our time in these 
programs asking families multiple times about ACEs every door 
they walk in would be a disaster and not trauma-informed.
    I think churches could be a great place to work with and 
help coach families in thinking through what is happening for 
you, what are your strengths, what do you want, what are your 
hopes, and also what do you need from the systems that serve 
you.
    And if we use IT platforms--we have been working on 
something called the Care Path for Kids--it is family driven 
where they own this tool and they can send it to whoever they 
want.
    And so the WIC program, the Head Start, their home visitor, 
their doctor all can see in one place what is it that we are 
dealing with, what is it we have strengths, and what do we want 
to have happen.
    So this is very important and I think churches would be a 
great place to implement that.
    Mr. Gibbs. Thank you.
    Mr. Cooper. I thank the gentleman.
    I now recognize Ms. Kelly of Illinois for five minutes.
    Ms. Kelly. Thank you so much. Thank you for your testimony 
and, again, thank the witnesses earlier.
    All too often in communities across the country, especially 
for communities I represent--I represent the Chicagoland area, 
the south side of Chicago and I go 100 miles south so I am 
urban, suburban, and rural--and in Chicago alone, and the 
number might have changed because it is a new day, there have 
been 240 people shot and killed already this year and 1,116 
shot but not killed--shot and wounded--since January.
    And can you imagine being a child? I know we talk a lot 
about mass shootings, but these are everyday occurrences in 
some of our neighborhoods. So imagine being a child and having 
to witness your loved one lose their life or dramatically limit 
their physical capabilities.
    It is an ongoing occasion, and I know one of my ministers--
we talk about PTSD, post-traumatic, and he always says, no, it 
is present traumatic because we live with this every day. You 
know, we don't send our kids outside. They can't play in the 
park. They are scared to walk to school. Some don't feel safe 
in the school because of the relationship with the police in 
some of the areas in Chicago.
    So from your research, what are some of the characteristics 
that can be observed from children who grow up in this--in 
these conditions? Do they graduate from high school? Are they 
likely, you know, to have successful careers? Because too many 
of them, when you say, what do you want to do, they don't even 
see themselves living past 20 possibly.
    Dr. Shervington. Yes. Sometimes we would be surprised with 
our kids who have those experiences when you ask them where 
they will be in, say, 10 years they say, on a tee-shirt, RIP. 
And so it has a tremendously profound effect on children 
growing up in this violence.
    We have done some work in our organization where we have 
looked at the data because we screen kids for signs and 
symptoms of PTSD, and I agree with you, it is present. It is 
persistent. It is not really post.
    And we find a large number, similar to Chicago, exposed to 
violence. At least 20 percent of the kids in our public schools 
have actually witnessed someone being killed. It gives them a 
very shortened sense of their own lives. One kid said to me, I 
don't know where I am going to school. You know, I am not 
learning. I am thinking about can I get home safely.
    We do know that if we can intervene when children are 
exposed to this level of violence, if we can intervene with 
them and help them process how it makes them feel, what it does 
to their feelings and to their thoughts, we can shift into that 
space where they are more thriving and flourishing because they 
can understand this is in the past but maybe there are things 
that can be better in the present and the future.
    Ms. Kelly. I just--I talk about the south side of Chicago 
but actually in my rural area I just met with 50 children from 
the 7th grade to seniors in high school and the things they 
shared with me, and someone asked about suicide, and farmers 
are a fast-growing group that are committing suicide because of 
what is happening, you know, in their lives lately.
    The other concern is one of the witnesses today talked 
about--I think she said they have one counselor for 400 kids, 
and some of our schools it is one counselor per--or social 
worker per two or three schools.
    You know, so that is something that is imperative that we 
get more counselors in to schools. And in Chicago some of the 
mental health facilities--I think there were six--shut down so 
not even access, you know, in the neighborhoods to go and get 
help.
    So that is something that we definitely--and I know the new 
mayor is interested in changing that so people have someplace 
to go to get help. And in my rural communities they are doing 
tele-health to help with that also.
    But just the effect of not having, you know, counselors to 
turn to is a very big issue. But I just want to thank all of 
you for your commitment and we are seeing the same thing. There 
are jobs but, you know, people don't have the technical acumen 
to take the job.
    They don't have to have a college degree. They could have 
high school. But because of the other things going on in their 
lives it has been very difficult for a lot of my manufacturers 
in particular to fill positions.
    I yield back.
    Mr. DeSaulnier.
    [Presiding.] Thank you.
    The chairman recognizes the gentleman from North Dakota, 
Mr. Armstrong, for five minutes.
    Mr. Armstrong. Thank you. I really appreciate the 
opportunity for this hearing today.
    You know, my grandmother was actually the head of the North 
Dakota Mental Health Association for 25 years. So I grew up 
dealing with this, and when you are talking about farmers you 
want to talk to rural German farmers in the 1970's and 1980's 
about talking about their feelings. That is a job that was--it 
is difficult to do now. Imagine doing it almost a generation 
ago. So we dealt with that.
    I also spent 10 years as a criminal defense attorney and I 
can tell you without a doubt that 85 to 90 percent of my 
clients, particularly first-time offenders under the age of 25, 
you can trace back to lots of different reasons and I think, 
ideally, we don't like to see a school nurse, a school 
counselor, and a school resource officer in every school all 
across the country.
    But we also know that the pipeline for those, even if we 
fully funded it for every rural school, every urban school, 
every whatever, we know the pipeline of the people coming in to 
those degrees doesn't fill those things.
    So what I think we have done both in criminal justice and 
in schools, which I think is great, is we have gotten law 
enforcement and teachers to be better at recognizing some of 
these things at an earlier age.
    I think one of the things--I mean, the number-one issue for 
North Dakota teachers is teacher safety right now. I mean, that 
is--that is about as heartland and as rural as it gets. So this 
is not only an urban issue. This is not only an East Coast or a 
West Coast issue.
    What I get concerned about is that we ask them to do too 
much often. I mean, if they are getting too--doing an in-
service every six months that does not make them a child 
psychologist. It does not make them a child social worker and 
it actually chases teachers out of the profession.
    And we are dealing with--like I said, I mean, if you are in 
a rural area in North Dakota you are a thousand miles away from 
a counselor, and tele-medicine and those types of things can 
help. I am glad we are talking about faith-based treatment 
because oftentimes in those small communities that is where the 
communal resource is.
    But there is also--I mean, there is other challenges. I 
mean, if you have done this for a long time and you walk 
around, I think we could walk into any 4th grade class and 
watch it for a week and have a pretty good idea of who we would 
probably want to talk to.
    But and we have talked about--you were talking about absent 
family base but, unfortunately, a lot--I mean, holding parents 
accountable only works if the parents are involved and want to 
be held accountable.
    So we end up dealing with some of these constitutional 
issues. We deal with some of these issues about family 
involvement and often are most at-risk kids, one of the reasons 
they are most at-risk is because their parents aren't involved 
for whatever reason.
    I mean, there is good reasons. There is bad reasons. There 
is all of those things. But we have been doing--so we have had 
to get creative. We have explored innovative ways to improve 
services for students through interconnected systems framework 
and blend school mental health and positive behavioral 
interventions for schools.
    I mean, it reduces barriers to learning, identifies needs 
early, engages in effective treatment options and improves 
educational life and outcome for students, which--and I do have 
to give a shout out to Jason Hornbacher, who is doing this in 
the Bismarck public school system, because all the policy in 
the world doesn't work unless you have really great people 
advocating this.
    So, I mean, my questions are one of the key tenets of that 
model is a broad network of connectivity for children.
    Dr. Houry, I suppose, but anybody can answer this, can you 
give us any detail on, I mean, how we integrate community and 
faith-based and just the different--I mean, every community has 
different resources available. We just have to look to them.
    I mean, are there programs and models that have worked in 
other places that everybody should be looking at?
    Dr. Houry. So a couple things. One is we are doing this 
right now in Cincinnati, Cleveland, and Detroit to where we are 
working with some of the cities to look at what programs we 
already have in place and really helping convene them because 
overtimes, I think, like Mr. Patterson was saying, there is 
lots of programs out there and you need to convene them and 
link appropriately.
    So I think that is really a key role for public health with 
the school system. I think even taking a step back earlier and 
looking at within schools it is great to have that response but 
really integrating things like social emotional learning like 
Good Behavior Game, Incredible Years type programs.
    That is primary prevention and gives kids coping skills, 
empathy, conflict management, life skills. So that when these 
stressors do occur, they are already prepared and that helps 
with the need for counselors.
    Ms. Bethell. I would like to speak to the issue that you 
raised about if you can't involve the families and the way that 
we really need to leverage well child care visits and others 
earlier on before children are even in school so the parents 
are really supported in their own well being and their own 
understanding about being involved without--and de-activating 
the shame of having issues so that we really create a norm that 
is more compassionate and so that they can stay involved 
through school and it is not just Band-aiding kids.
    But I also want to raise something called the self-healing 
communities model, which was implemented in about 42 
communities in Washington State, and through these programs 
when they evaluated them that those communities that were able 
to come together and integrate school and child welfare and 
health care and churches and others really saw a reduction in 
at least five kinds of outcomes, things like youth violence, 
substance abuse, teen pregnancy, and suicide. The reduction in 
caseload alone for child welfare and juvenile justice yielded 
about $176 per dollar invested.
    Mr. Armstrong. Wow.
    Ms. Bethell. So $3.4 million invested and $601 million just 
for the few things that you could measure. So the power of 
self-healing communities coming together. But what they need is 
support.
    Process needs to be supported in this time to be invested, 
and then once we get those under our belly, you know, and we 
know how to do it, it can be self-perpetuating. But right now, 
these skills are not in place.
    Mr. Armstrong. And I agree with that and I know my time is 
up, and I would say the process needs to be supported but we 
also always have to recognize it needs to be flexible because 
we have to deal with these things with the resources we have, 
not the resources we wish we had.
    Ms. Bethell. And that is the self-healing community's 
model. I encourage you to look at it.
    Mr. Armstrong. Thank you.
    Mr. DeSaulnier. In the spirit of self-healing, the chair 
will now recognize the gentleman from Tennessee, Mr. Cooper.
    Mr. Cooper. I thank the chair, and I would first like to 
add my congratulations to our colleague, Ms. Pressley, for the 
historic nature of this hearing.
    I wish attendance were better because every one of my 
colleagues needs to hear your testimony, and not just as often 
happens in Congress--not just pay it lip service--because this 
is pretty rare to have an entire panel that is genuinely on the 
side of children, the angels.
    It is also pretty rare to have an entire panel these days 
that is on the side of science, which translated means 
government-funded research. So people have to get over it and 
support it.
    I have a particular need to single out my friend and 
colleague, Mr. Henry from Tennessee, a remarkable public 
servant. Now, how he ever overcame the handicap in Madison, 
Tennessee, of having been raised by, I am guessing, 50 
Republican relatives that is quite--that might be an ACE. I 
don't know.
    [Laughter.]
    Mr. Cooper. But his career in our state legislature where 
he was a giant, his career in the business community serving 
the underserved, his career in the executive branch not only in 
the cabinet but as a deputy Governor is extraordinary.
    So I thank you. I wish we had more people like you. In 
fact, if you want to run for office in Tennessee statewide 
since Democrats have a difficult time doing that you might be 
the best we can get. But I don't want to hurt your campaign 
with an endorsement right now.
    But the elephant in the room is this. Can we really help 
our kids in states that have refused to even extend Medicaid? 
Mr. Henry worked hard. Governor Haslam's Insure Tennessee plan, 
which you and I were both strongly for but our legislature 
would not even give the time of day--so our state is giving up 
a billion dollars a year in health care for poor families and 
the kids.
    So I would first like to ask our three doctors on the panel 
is it possible to help kids as you suggest in a state that 
refuses to even extend Medicaid and to give up all that money 
that could be used for health care for these poor families? 
What is the answer to that question? Because that is 
politically the most pressing question that at least 14 states 
face.
    Dr. Shervington. And my response is not political. It is 
just human. As a physician, I have seen when a child really 
needs help, that because they don't have the insurance and for 
poor children it is usually Medicaid, they do not get the type 
of service they need, the quality of service they need.
    Unfortunately, what I have seen in another experience when 
I worked in forensics where there were people on death row, and 
as a psychiatrist I was asked to see them. I could get a lot of 
money at that point when all the damage had been done. And so I 
would like for us to really think about back to prevention.
    For many of those men that I saw, the traumas that they 
experienced, if there had been access to health care at that 
time and they perhaps would have been referred to some 
therapist, psychiatrist, psychologist, maybe they wouldn't end 
up now with someone like myself trying to get them mercy and 
not the death penalty.
    So we need to have our children have access to health care.
    Ms. Bethell. So I would like to address your question from 
a data point of view but first from a personal point of view.
    I was one of the first babies on Medicaid in California and 
I was hospitalized 11 times and saw a lot of ER doctors, and I 
would be dead without Medicaid.
    There is no question about it, and I can tell you my story 
another day. But I would be dead. Now, I wish the providers 
were more trauma-informed because they could have done a lot to 
help my mother, which is really what--who needed help, right.
    So we need to integrate Medicaid services to be family 
based, not only just for children but to allow pediatricians 
and family physicians to cut across and help the mother or the 
father because that is often what needs to happen. To help 
children we have to help adults.
    Now, for a data picture, this is in my testimony written. 
There is wide variation across states in how many children have 
special health care needs based on whether they have ACEs, wide 
variations in terms of whether they have emotional mental 
behavioral problems, bully, whether they are flourishing, 
whether their families stay hopeful in difficult times, and I 
can show you that in the states that do not have more generous 
Medicaid benefits that there tends to be higher rates of these 
problems.
    Mr. DeSaulnier. Thank you. Thank you, Mr. Cooper.
    The chair will now recognize Mr. Raskin of Maryland for 
five minutes.
    Mr. Raskin. Mr. Chairman, thank you very much.
    I also want to salute Ms. Pressley for having the idea for 
this excellent and important panel discussion.
    Let us see. Ms. Bethell, I want to start with you. Are you 
at Johns Hopkins?
    Ms. Bethell. I am.
    Mr. Raskin. You are? Good. Okay. So you are a Marylander so 
I want to start with you. The question before us today is 
important, obviously, for humanitarian reasons, and this is a 
week where a lot of us are focused on the condition of children 
in our care and custody.
    But it is also important in terms of the future. I saw a 
documentary about abuse of kids at a Catholic girls school in 
Baltimore, which is just utterly horrifying and shocking. But 
how do you break the--how do you break the cycle of trauma? 
Because the people who are--who are the victims of it can 
themselves become the perpetrators, right, later.
    So what do we know about that?
    Ms. Bethell. I mean, I would like Dr. Shervington also to 
contribute. But what we know is that when people experience 
trauma and become perpetrators, they are deep in their own 
self-shame and their lack of self-worth, and the inability to 
imagine it could be different and have a lot of hopelessness.
    And so one of the first things we need to do is recognize 
that until people have something to live for and they can have 
their shame deactivated so they can understand that something 
happened to them because that is what the pattern is that we 
are not going to be able to really engage them in the kinds of 
healing processes that they have to go through to not be facing 
an amygdala that basically hijacks them with anger and leads 
them to lash out that they often regret later but it does 
damage, because these are very basic biologic mental and neural 
capacities to be able to handle stress, and when you have had 
that happen to you as a child and you become a parent it can be 
almost impossible to control yourself if they are on the 
perpetrating side.
    So, you know, we really need to protect children and we 
also need to help the perpetrators in very clear ways who are 
often really suffering themselves.
    Mr. Raskin. Thank you.
    Mr. Patterson, the Cincinnati Enquirer says that 1.2 
million Ohio residents have gotten health care coverage through 
the Medicaid expansion. Of those, about 630,000 receive 
treatment for mental health or drug abuse problems and 290,000 
people left Medicaid after getting a job or increasing their 
income.
    What would the impact be of rolling back the expansion of 
Medicaid coverage in Ohio today for children who have 
experienced trauma?
    Mr. Patterson. It would be a devastating impact because 
those perpetrators who are able to now seek treatment through 
mental health services through--for their--for their mental 
illness or their substance abuse illness would no longer have 
that capacity.
    And I will tell you that in our community if you don't have 
Medicaid or you don't have another insurance, you are not 
getting treatment. There is no free treatment, and so the cycle 
will continue or will actually get worse if we pull back what 
happened.
    I am sure you know in our state, you know, our legislature 
didn't act on that either.
    Mr. Raskin. Right. Well, I appreciate that answer.
    Mr. Henry, the program that you led in Tennessee is called 
Building Strong Brains Tennessee, emphasizing that brain 
function and neurological resiliency can be strengthened 
through specific interventions, a theory that was informed by 
several scientific symposia and studies and findings.
    Can you discuss the importance of drawing on scientific 
data to create public policies that address the impact of 
childhood trauma?
    Mr. Henry. I think that it is incumbent upon all of us to 
draw from everywhere we can and, you know, the impact of us not 
getting the expansion dollars, I mean, it is kind of a amazing 
what we would be--where we would be right now if we did, and--
--
    Mr. Raskin. Did you try to use science in the process of 
convincing people in Tennessee of the----
    Mr. Henry. We couldn't get it on the agenda. Neither 
speaker would bring it to the floor.
    Mr. Raskin. Maybe you are the right person to comment on 
this first--anyone else who has expertise on it. But I was 
fascinated by the finding that kids who experience trauma are 
more than doubly more likely to be bullied by other kids, which 
was a shocking thing to read. You would think it would be the 
opposite, that the kids would be more sympathetic and tender.
    But what is the basis for that finding and what can be done 
about that problem?
    Mr. DeSaulnier. And before you go ahead, Mr. Raskin, I am 
advised that votes are about to be called. So I want to get as 
much testimony and questions as possible in. So if you could be 
concise in your response so I can go to Mr. Rouda.
    Ms. Bethell. Yes. I will just say that actually someone 
earlier said that, you know, there is different ways that 
people act out in trauma. They act out and it is more assertive 
and aggressive and we can see those behaviors.
    But there is also an acting in, and children who have ACEs 
can often appear to be very vulnerable and to be victims of 
people who are more perpetrating. But they both share probably 
a lot of ACEs.
    Most of the children who bully have ACEs and most of the 
children who are bullied have ACEs. It is both.
    Mr. DeSaulnier. Thank you. An important point.
    Mr. Rouda?
    Mr. Rouda. Thank you, Mr. Chairman, and thank all of you as 
well as the previous panel for joining us today, and as 
Chairman Cummings said at the very beginning, I apologize. I 
haven't been able to be here for the entire testimony. But, 
fortunately, we have had the opportunity to read it in advance 
and dig into this issue deeper.
    I would like to talk about homelessness because it is an 
issue that has been very important to my wife and I. When we 
were in our 20's my wife read an article about the plight of 
homeless families, and at that time the typical situation is 
you lose your job, you lose your home, you live in a motel, 
hotel. You live in your car.
    When that money runs out, and then you go to a shelter 
where often they would take the families and they would send 
the men and boys 15 years and older to the men's shelter and 
the women and the children to the women's shelter, when all 
that they really have left at that time is the family unit. And 
we know separating kids from their parents is not good, whether 
it is due to homelessness or due to being on the--on the 
border.
    We right now in America have 550,000 Americans experiencing 
homelessness and about one-third of that population is 
children. In my county, Orange County, California, it is 7,000 
homelessness and 1,000 homeless children with approximately 
27,000 children experiencing home insecurity on an annual 
basis.
    The annual report on the conditions of children in Orange 
County states, ``The high mobility, trauma, and poverty 
associated with homelessness and insecure housing creates 
educational barriers, low school attendance, developmental, 
physical, and emotional problems for children.''
    And Dr. Shervington, in your written testimony you 
identified homeless youth as showing higher and multiple rates 
of exposure.
    Would you agree that reducing the number of homeless 
families and youth must be part of the effort to reduce 
childhood trauma?
    Dr. Shervington. I can be brief. Absolutely.
    Mr. Rouda. Thank you.
    And the Center also stated children in previously homeless 
families receiving rental assistance vouchers changed schools 
less frequently and are much less likely to be placed into 
foster care than other homeless families, one study found.
    Their families also experienced significantly less food 
insecurity and domestic violence. And, again, Dr. Shervington, 
why is having a safe and stable home so important to a child's 
development?
    Dr. Shervington. Children really do rely on the capacity of 
their caretakers to create an affectional bond with them. It is 
within that experience that they are going to learn that the 
world is safe, that it is secure, that they can begin to create 
their own identities of themselves and other people.
    When that is interrupted, then we set the foundation for 
the inability of that child to pull on their own inner ability 
to be resilient, plus all the other factors that they will----
    Mr. Rouda. Thank you.
    And, Mr. Chairman, I ask unanimous consent to enter into 
the record reports that show childhood homelessness and housing 
insecurity is associated with the factors I pointed out, and 
the stories regarding critical and innovation work being done 
by organizations across Orange County including the Family 
Solutions Collaborative, Families Forward, Mercy House, First 
Five Orange County, Orange County United Way, and Jamboree 
Housing to get families off the streets and connect them with 
the services that they need to succeed.
    Mr. DeSaulnier. Without objection.
    Mr. Rouda. Thank you, Mr. Chairman.
    Also, I think what is very important too in this discussion 
is that when we have preventive opportunity to address 
homelessness it is actually a lot cheaper than dealing with the 
consequences of that trauma down the road.
    And I do want to take the remainder of my time and yield to 
Congresswoman Pressley for the remaining time.
    Mr. DeSaulnier. Go ahead, Congresswoman Pressley.
    Ms. Pressley. Thank you so much.
    I want to talk about the criminal justice system. An 
estimated 90 percent of children in the juvenile justice system 
have at least two ACEs, which is what was testified to earlier, 
with 27 percent of boys and 45 percent of girls in the justice 
system having five or more ACEs.
    What is the impact of a punitive response to trauma rather 
than a public health approach?
    Ms. Bethell. Well, I think--I wish we had a lot more time 
but, basically, when you are traumatized you already--your 
sense of self-worth and hope in life is often very diminished, 
and when you continue to be treated like that it is diminished 
further.
    And the neurobiological effects of those identities of I am 
not worth anything, I don't have hope, basically perpetuate 
continued pruning in your brain, a lack of ability for self-
care, and you are not able to really take advantage of any of 
the supports that might be given in the justice system to help 
you.
    So on the one hand we are saying help yourself, fix 
yourself, do all these healthy behaviors, and then being 
treated like that, which it systematically prevents a person 
from being able to even take advantage of the support they are 
being offered.
    So until we help people understand it is not what is wrong 
with you--it is what happened to you, and it is not what 
happened to you, it is how it impacted you and getting close to 
that, and it is not how it impacted you, it is what can we do 
about it, and they are onboard with that because they feel like 
somebody cares about them and they are valuable while they are 
learning to care about themselves again, which they may have 
never even felt that I am worth anything, and that is a very 
common report that we hear from young people today.
    Ms. Pressley. And I am sorry. I just wanted to pick up, and 
again, I thank--Harley, thank you.
    I wanted to ask you--you referenced a self-healing and 
community model, which does need to be the goal ultimately so 
that we have something that is self-perpetuating and has that 
agency and is sustainable because not only do we need a 
response that is coordinated and comprehensive, that is 
equitable for everyone from a survivor of sexual assault to the 
survivor of a shooting on a city block to a mass shooting to 
PTSD from war--comprehensive and equitable.
    But it has to be sustainable and I do worry about our 
ability to just have systems, which have often already failed 
people, right--broken systems creating broken people--and 
whether or not they can even offer a sustainable solution in 
the long run.
    So how do we get to that and could you tell me the model 
where is it from--the self-healing community model?
    Ms. Bethell. The self-healing communities' model----
    Mr. DeSaulnier. And Dr, if--once again, admonition. Just 
try to be concise, just because votes are about to be called.
    Ms. Bethell. Okay.
    Ms. Pressley. Yes. I am so sorry.
    Ms. Bethell. I can----
    Mr. DeSaulnier. No, I appreciate it.
    Ms. Bethell. I can provide you with the specific reference 
from that but it is in Washington State and it is easily found.
    Ms. Pressley. Okay. Great.
    Ms. Bethell. Robert Wood Johnson Foundation has published 
on that. So I can definitely provide that.
    Ms. Pressley. Okay.
    Ms. Bethell. But until the community is engaged in driving 
the change and working with systems who are receptive to their 
needs and ideas about what they need, I don't think we will 
ever have a sustainable system.
    Ms. Pressley. Okay. Thank you so much.
    Mr. DeSaulnier. Thank you.
    I want to acknowledge Ms. Pressley once again and her 
leadership. Having been a resident of Boston many years ago and 
having worked for the Boston juvenile court many, many years 
ago, Massachusetts, the Commonwealth, has done a lot of great 
work and you have been at the forefront of that.
    I also want to recognize the witnesses from the first panel 
and the one who is still here. In my view, you are so powerful 
and what you did today made you and your three colleagues at 
the first panel the most powerful people in Washington, DC, and 
it is transformative.
    Having had this experience, multiple generation of 
addiction and abuse in my--with my parents, with my siblings, 
and with children in my family, I have visited this issue as a 
personal issue and a private issue.
    I am reminded, sitting here with this panel, many years ago 
when I was a county supervisor and then Governor Pete Wilson, a 
Republican, introduced the California Continuum of Care for 
Children and Families, and an advocate at one of the hearing 
saying this is like a metaphor for there is a group of parents 
by the side of a rushing river and children--young children are 
drowning in the river going downstream, and the parents, the 
adults, kept jumping in the river saving one at a time and then 
finally one of the parents said, somebody needs to go upstream 
and find out why these kids are going in the stream.
    And 30 years later, I still think of that. So in this 
context of knowing, the 30 years since my father took his life 
to now, we are at this inflection point.
    The exponential research Dr. Houry and I talked about 
yesterday--being from the Bay Area we talk about Moore's Law 
and technology--the research in neuroscience puts that to 
shame.
    I tell my kids when we look back at this period of time--
when they do and their kids--they will look at us as both 
barbaric but as transformative if we do what we need to do.
    So we know with the ACA and with parity we have 75 percent 
more requests for referrals even with this broken 
infrastructure, but to the point from the gentleman about 25 
percent less people going into the professional classes to 
serve these people.
    So the two things I would question, Dr. Houry and Dr. 
Bethell, in particular are costs. We talked about this 
yesterday when we met. CDC says that--estimates in 2015 that 
maltreatment of kids, going upstream, is $2 trillion a year in 
the United States.
    And besides the human costs that we have heard about and 
for all of the examples that we heard today about people 
overcoming, and I would recommend ``Supernormal'' by Meg Jay, a 
wonderful researcher, or anything written by Kate Jameson, who 
is a survivor of our own suicide.
    The more we go upstream it is--but we are losing people 
because we don't have the infrastructure to match the 
increasing neuroscience and evidence-based research.
    Now, in this--in this Congress we were able to do 
bipartisan good work on evidence-based research when it came to 
the criminal justice system. It wasn't perfect, by my 
standards, but we agreed that the science would inform our 
decisionmaking process.
    So we have that cost, and then as a survivor of cancer I am 
very appreciative. I went to see my oncologist today. The 
cancer I have 15 years ago I would be dead. But now I have got 
an extended lifetime.
    NIH says that $77 trillion since 1974 their research has 
contributed to the U.S. economy. Seventy-seven trillion 
dollars, because investments in science and research.
    So how do we take the fact that people lose their lives 14 
to 32 years sooner if they don't have the treatment they need, 
and then the costs, both individually and to the whole society.
    And then the other--the examples of when we got this right, 
cancer being one of them--cardiovascular disease. When we 
accepted what you did at CDC and what people did at NIH and 
then deployed it, Dr. Bethell, using the infrastructure as best 
we can that we have, to Ms. Pressley's comments about juvenile 
justice.
    Recently, I was in our juvenile hall, which I was an 
advocate to rebuild when I was a county supervisor 15 years 
ago, the judges and the DA told me it is not big enough; we are 
going to have to find another space.
    It is now 60 percent to capacity. I asked a former 
presiding juvenile chief, who is a friend of mine, what 
happened and she said, we took all those programs that were 
evidence-based research and now the kids aren't in here. They 
are out in the community getting the services they need, and 
they are not hurting themselves or anyone else.
    So those two things, first, Dr. Houry, how does the 
Congress approach this from an evidence-based research, use 
that research as we did with criminal justice reform, and get 
to savings and the life expectancy changing in our lifetimes or 
sooner?
    Dr. Houry. Thank you.
    Well, I would say prevention saves lives. When you look at 
number of adverse childhood experiences, we have seen that if 
you have, like, six or more decreases life expectancy by, you 
know, 18 or 20 years.
    So I think that is one thing right there. If we can, you 
know, impact early on, reverse these traumas, buffer them, that 
will impact life expectancy.
    On our website, we have information on evidence-based 
programs--child-parent centers and nurse-family partnership. 
Every dollar spent on a nurse-family partnership saves $6.38.
    I plugged in the chairman's state of Maryland just to see 
what would happen if they implemented it statewide. They would 
save over $200 million in substantiated child abuse cases. That 
saves money.
    And you look long term, all the other health impacts that 
Dr. Bethell and Dr. Shervington talked about with 
cardiovascular disease, diabetes, substance use, that early 
investment in prevention will have that long-term impact.
    Mr. DeSaulnier. Dr. Bethell, we are having the bells ring 
so we want to go vote.
    Ms. Bethell. Okay. Great.
    Mr. DeSaulnier. I feel sorry that I have had to tell people 
to be concise for something we, clearly, all want to talk about 
for a long period of time.
    Ms. Bethell. I just want to really support your statement 
that this is a crisis. The Children's Hospital Association has 
put out a report on how it is a matter of national security 
what is happening even just when we look at the lack of 
flourishing of children and how that might play out for 
adulthood.
    We need a stream of launch and learn supports that allow us 
to use the best evidence we have and create citizen science 
platforms and in every NIH RFP that is about human health 
needing to look at this to advance the science in all of our 
systems and professional associations.
    But most importantly, healing is prevention. We are at a 
point in this syndemic, meaning it has escalated to a point 
that even if you don't have ACEs you are impacted.
    And so it is all of us, and healing has to lead the process 
for prevention, because if we offer things and they are not 
used because there is too much trauma it is not going to really 
work.
    But the ``through any door'' investments need to happen 
like we built the roadways. We had to invest in those roadways 
so that we could build this Nation.
    We need to build social infrastructure and that will play 
out, and it is time for that investment when our sciences and 
our lived experience can finally meet policies that pay for and 
invest now, because we will save later and we will also have a 
lot more joy and well being as a country.
    Mr. DeSaulnier. Well said. I think that is as good a place 
as any to conclude, but also say that I want to thank the 
chairman, Mr. Cummings in particular, and again, Ms. Pressley, 
for their interest, and my colleagues on this bipartisan very 
important hearing, and again to the panelists on this panel and 
the previous panel.
    So with that, without objection the following statements 
will be part of the record: a statement on childhood trauma 
from the National Education Association and a statement from 
the National Juvenile Justice Delinquency Prevention Coalition.
    Mr. DeSaulnier. Okay. The ranking member says no, he wants 
to get to vote. So with that, I would like to thank once again 
our witnesses for testifying. It was incredible.
    Without objection, all members will have five legislative 
days within which to submit additional written questions for 
the witnesses to the chair, which will be forwarded to the 
witnesses for their response.
    I ask our witnesses to please respond as promptly as you 
are able.
    This hearing is adjourned. Thank you, again.
    [Whereupon, at 1:38 p.m., the committee was adjourned.]

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