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    Testimony

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    Statement by
    Charles G. Curie, M.A., A.C.S.W.
    Administrator, Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services
    on
    The Effects of Trauma on Children and the Role of Mental Health Services
    before the
    Senate Committee on Health, Education, Labor and Pensions

    June 10, 2002

    Good morning Senator Clinton. Thank you for inviting me to participate in this field hearing focused on the effects of trauma particularly that of September 11 on children. I am Charles Curie. It is my privilege and honor to serve this Administration and Health and Human Services Secretary Tommy Thompson as the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (HHS).

    Our mission, as envisioned by Congress 10 years ago when SAMHSA was created, is to "fully develop the Federal government's ability to target effectively substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system." SAMHSA's work has shown that prevention, early intervention and treatment for mental and substance use disorders pay off in terms of reduced health care costs, educational and job losses, suicide, homelessness, crime, and, sometimes, violence. Data confirms that the human and economic costs are much lower when we prevent or intervene early with the best research-based tools available. Mental health services can and do increase productivity, employment and community participation.

    When it comes to the lives of children, SAMHSA's emphasis on and support for prevention and early intervention can make the difference in a child's future helping to fulfill the promise of a productive and fulfilling adulthood. Today, the need to achieve that mission could never be more important; the opportunity has never been greater particularly when we focus on the mental health implications of trauma.

    In the wake of September 11 even more than following Oklahoma City or Columbine or Jonesboro America's consciousness about trauma and our ability to be resilient in the face of adversity have been heightened as never before. As never before, we have the ability to help end the stigma surrounding the emotional products of trauma emotional problems, and sometimes even, mental illnesses like depression, anxiety and PTSD. This hearing can be an important part of that effort.

    Trauma What It Is

    From the perspective of the mental health clinician and I am a social worker the term "trauma" has definitions related to both body and mind. From the physical perspective, trauma as we all know refers to a serious or critical "bodily injury, wound, or shock." From a mental health perspective, trauma assumes a different meaning, referring to a "painful emotional experience, or shock, often producing a lasting effect."

    Traumatic events can involve a life-threat, severe physical injury, loss of a primary caretaker, or loss of one's community or social environment. Trauma also can pose a threat to an individual's sense of psychological control, or physical or psychological integrity.

    Trauma may result from a broad range of occurrences of either natural or human cause: (a) physical/sexual abuse or assault; (b) natural or man-made disasters and catastrophes (e.g., tornado, earthquake, mass shooting or terror attack); (c) physical injuries or incapacitation (e.g., motor vehicle or bicycle accidents, animal attacks, or other serious accidents); (d) chronic, severe, or painful medical conditions or invasive or painful medical procedures (e.g., repeated surgeries for Krohn's disease in childhood, cancer, etc); (e) witnessing or experiencing family or community violence; (f) traumatic loss of family members, friends and other significant attachment figures; and (g) exposure to war, terrorism, kidnappings, political oppression and forced displacement. Trauma can be the result of single or repeated events; it can be a product of chronic exposure to or experience of a condition. And the experience of trauma may be direct or indirect in nature. Many types of trauma whether experienced directly or indirectly have both short-term and long-term effects. These can include problems such as acute physical injuries, such as burns, that result in chronic pain, disfigurement or disability, or repeated episodes of childhood abuse that result in short-term physical damage and longer-term emotional pain.

    We treat the effects of physical trauma setting broken bones, stitching wounds. We can and should do no less for the psychic effects of trauma whether those effects are immediate (e.g., grief reactions, depression) or longer term (e.g., post-traumatic stress disorder, chronic depressive illness or anxiety disorder). We have the scientific knowledge the evidence base from which to act when it comes to treating people experiencing the short- or long-term effects of trauma. Equally important, however, we know now what risk factors and protective factors may make an adult or a child more or less able to "bounce back" from traumatic experience. We know how to help promote resilience even among those at greatest risk for emotional disturbance.

    When It Comes to Children

    When it comes to America's children, from both physical and emotional perspectives, they have both the greatest capacity for healing and the greatest capacity for scarring as a result of trauma. Their capacity for resilience is so very important to their future and ours. After all, childhood exposure to traumatic events is not uncommon in children and adolescents. In 1998, an estimated 200,000 children were victims of physical child abuse; 100,000 were victims of sexual abuse; and 225,000 were victims of multiple forms of child maltreatment. Each year approximately 140,000 children and adolescents receive treatment for bicycle-related head injuries; almost 20,000 children are hospitalized because of burns, and 5 of every 100,000 children, aged 0-10, are hospitalized for dog bites. These and other events experienced in childhood and adolescence can have a detrimental effect on the health, well-being and development of affected children and adolescents.

    When it comes to the potential for trauma related to events of September 11, the effects on children in New York City are starkly evident in a study reported in the New England Journal of Medicine. Based on reports from parents, that study found that 35% of children had one or more stress symptoms nightmares, sleep problems, distractibility, withdrawal, anger that could point toward a more serious problem such as PTSD. Forty seven percent were worried about their own safety or the safety of a loved one.

    The good news is that considerable progress has been made in understanding the prevalence, characteristics, risk factors, and consequences of trauma in children and adolescents. Unfortunately, not all of the fundamental questions for which we need answers have been adequately addressed. For example, we would benefit from being able to predict which children will experience the most detrimental effects of trauma exposure, the impact of trauma on developmental processes across the stages of development, and knowledge of the specific underlying biological, psychological, and social processes that we can target for the most effective treatment and preventive interventions.

    Intervention in the aftermath of trauma is perhaps the most significant clinical issue in child and adolescent mental health. The vast majority of children who experience trauma particularly catastrophic events are able to cope with the event and its consequence by themselves or with support from family, peers or other adults; others suffer only worries and bad memories that fade with time. Yet, for some, the trauma can precipitate chronic serious mental health issues such as depression, chronic anxiety and PTSD; some youth may seek drugs or alcohol to cope with these emotional difficulties. [We know, for example, from Vlahov's seminal study, that in general, the use of alcohol, tobacco and marijuana in New York City increased immediately following September 11.]

    Promising interventions for child trauma have been identified, but much more needs to be done to provide these services to children and their families. The scientific evidence-base is not strong on many critical intervention issues, such as what types of interventions maximize trauma recovery, which children and which types of trauma exposure are effectively treated by different interventions, and how interventions should best address developmental issues. Using what knowledge does exist, SAMHSA will be working to identify best practices in prevention and early intervention that can be adopted and adapted to respond to child trauma in its varied forms. I'll be addressing this issue in greater depth later in this testimony.

    For the vast majority of children, their schools are where signs and symptoms of potential response to trauma withdrawal or its opposite, aggression; plummeting grades; or depression are first identified. Thus, schools represent the largest child service system in which there is an opportunity to recognize and take action on a child suffering from trauma. Some progress has been made in developing procedures to identify children affected by exposure to traumatic events and provide trauma-focused treatment in school settings. Development and implementation of effective identification, assessment and treatment approaches in this and other child service settings would have a significant impact on the mental health of children.

    In fact, schools played what we may discover will have been a critical part as a site for early intervention for children and in some cases, even their families in New York City immediately following the attack on the Twin Towers. School-based specialists who were working with children around resilience building and risk reduction for substance abuse stayed at the schools. Their training enabled them to provide immediate counseling and assistance to the children and families. Moreover, some of the school prevention specialists are providing ongoing follow-up with children at particular risk such as those who lost parents in the terror attacks. While it is far too early to tell, it is likely this kind of early engagement while not always needed by all children may help delay or avoid later longer-term traumatic responses, some of which I will discuss later in this testimony.

    How Children and Adolescents React to Trauma

    After a frightening or distressing experience such as an assault (sexual or physical), fall, fire, a car crash, earthquake or other natural disaster, war, traumatic death, or captivity, the survivor may suffer psychological stress in addition to any physical injuries. An estimated 70 percent of adults in the United States have experienced some kind of traumatic event at least once in their lives.

    When it comes to mental health services, even though children can't be treated simply as if they were little adults, they, like adults, may display a wide range of emotional and physiological reactions following disasters and other traumatic events. Reactions may appear immediately after the traumatic event or, days even weeks later. Research into trauma responses has helped us know who may be placed at greatest risk for more severe emotional responses. We know, for example, that more severe reactions among children are associated with closer proximity to the event. Children and youth whose experience of the traumatic event poses a life threat or physical injury, who witness death or injury, who hear screams, etc., are at greater risk. Other risk factors include a history of prior traumas, female gender, insufficient or inappropriate parent support or response, and the mental health status of the parent(s). Thus, not surprisingly, findings from a study following the Oklahoma City bombing indicate that more severe reactions were related to being female, knowing someone injured or killed, and bombing-related television viewing and media exposure.

    During and immediately following a traumatic event, children and adults as well can experience feelings of panic, helplessness, uncontrollable fear or terror, that may lead to a range of acute and chronic emotional disorders. The American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) identifies and specifies the characteristics (symptoms) of several specific syndromes associated with exposure to stressful and traumatic events: post-traumatic stress disorder, acute stress disorder, and adjustment disorder.

    Studies of adults have found that up to 20 percent of people who have experienced a traumatic event go on to develop post-traumatic stress disorder as noted above, a diagnosable and treatable mental illness listed in the DSM-IV. PTSD is the name given to what actually are a constellation of symptoms and reactions that may follow a traumatic experience. Professionals who respond to victims in trauma situations such as emergency medical service workers, police, firefighters, military, and search and rescue workers are at particular risk, as we saw during the Vietnam and Gulf Wars, and even more recently following September 11. However, PTSD is not limited to adults.

    Recent studies show that PTSD is far more common among children than previously believed. Depending on the type of trauma, rates of PTSD identified in child and adult survivors of violence and disasters vary widely. For example, estimates range from 2% after a natural disaster (tornado), 28% after an episode of terrorism (mass shooting), and 29% after a plane crash. As noted for the general population, three factors have been shown to increase the likelihood that children will develop PTSD: (1) the severity of the traumatic event; (2) the parental reaction to the traumatic event; and (3) the physical proximity to the traumatic event. In general, most studies find that children and adolescents who report experiencing the most severe traumas also report the highest levels of PTSD symptoms.

    But PTSD isn't the only problem a child may experience in the wake of a traumatic experience. The impact of trauma on the functioning of children and adolescents can be pervasive. The effects of trauma on the still-developing body and mind are significant. Other effects of trauma can include depression, anxiety and chronic or impulsive outbursts of anger; suicide attempts; antisocial behavior, including substance abuse; feelings of hopelessness, chronic shame or guilt; academic problems resulting from learning, memory, and attentional difficulties; and interpersonal problems.

    The good news is that children like the vast majority of Americans are a resilient group. The majority are able to cope effectively with the aftereffects of their trauma exposure through their own resilience, and with support of family and others, and may even derive positive benefits from their experiences. Most children and adolescents, if given support, will recover almost completely from the fear and anxiety caused by a traumatic experience within a few weeks. However, some children and adolescents will need more help, perhaps over a longer period of time, in order to heal.

    After the Traumatic Event: Identifying Treating Post Traumatic Stress Disorder

    There are many things that can be done to help children who have experienced trauma. In the immediate aftermath of a traumatic event, and in the weeks following, it is important to identify the youngsters who are in need of more intensive support and therapy because of profound grief or some other extreme emotion. That's why those prevention specialists in the schools were so valuable. A list of symptoms and behaviors that may help parents, teachers and other caring adults identify a child who may be at serious risk is appended to this statement.

    We have learned that, in general, children and adolescents with greater family support and less parental distress tend to have lower levels of PTSD symptoms. Children and adolescents who are farther away from the traumatic event also report less distress. PTSD, depression, anxiety may resolve without treatment. However, in the case of PTSD, some form of therapy by a mental health professional often is needed to foster healing that lasts over time. PTSD in adults most often is treated with specialized forms of psychotherapy and sometimes with medications or a combination of the two. Research is just beginning on the use of medications to treat PTSD in children and adolescents. A mental health professional with special expertise in the area of child and adolescent trauma is the best person to help a youngster with PTSD.

    Mental Health Effects of Terrorism on Children

    I want to focus, for a moment, on the effects of terrorism on children; after all, September 11 was nothing if it was not an act of terrorism. Two main groups of children appear at risk for traumatic reaction following events such as these: those who were present or observed the event and who are at risk for developing PTSD, and those who lost a loved one. For example, children who were in the World Trade Center (WTC) during the 1993 bombing showed significant levels of PTSD and disaster-related fears, similar to findings reported after other disasters involving severe life threat. Children who reported a friend killed in the 1995 Oklahoma City bombing reported post-traumatic stress symptoms eight to 10 months after the incident, as did children with the most bomb-related television viewing.

    Certain post-traumatic interventions can help reduce levels of PTSD and depression substantially, thus effectively altering the natural trajectory of post-disaster impairment. Left untreated, child PTSD and related conditions can endure for years and lead to long-term impairment and missed developmental opportunities. We owe our children with psychic wounds no less than the support and caring, intervention and treatment than we provide to those with wounded bodies. There is no better place to begin than here in New York. All you need to do is to look at the faces and hear the voices of the children and adults on our first panel to know exactly why.

    Substance Abuse and Mental Health Services Administration and other HHS-related Efforts

    When I was first named by the President as his nominee for SAMHSA Administrator, I thought long and hard about critical issues on which I believed SAMHSA should focus its mental health and substance abuse treatment and prevention services programs. Ironically, among those issues was trauma and violence. Little did I know the level to which that priority would rise in just a few months. But, I am proud to say that SAMHSA like much of the government and the Nation as a whole rose to the occasion.

    Within days of September 11, the US Department of Health and Human Services, including SAMHSA, responded immediately to crisis.

    Within 24 hours, thanks to hard work by Secretary Thompson and Departmental staff, both SAMHSA staff and $1 million in immediate Department of Health and Human Services resources were on the way to the State of New York. Within a week, additional personnel and an additional $6.3 million were made available to all nine of affected jurisdictions. Within a month, another $20 million was awarded.

    Within two months, SAMHSA convened a Pre-Summit, where the 9 most directly affected jurisdictions to shared their experiences and set an agenda for a national summit 3 weeks later. At that national summit, almost 700 individuals representing 42-states, 5 territories, the District of Columbia, 2 Tribal Governments, and over 100 other key stakeholder organizations participated. The result: States have made progress toward finalizing their own disaster/emergency plans that include both mental health and substance abuse.

    SAMHSA and its sister research agencies, the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) have developed and implemented grant programs and activities that are designed to move new knowledge about the effects of trauma to services programs nationwide. For example, the NIMH in April made 10 awards to researchers who are working to yield information specific to the mental health implications of September 11 or to yield clues regarding the best ways to design and undertake large-scale studies on prevention and treatment of mental illnesses resulting from exposure to mass violence. Working through an interagency agreement in the spirit of moving science to services in an expeditious way, SAMHSA and NIDA are working to assess the effects of September 11 on the drug dependent population.

    At the same time, SAMHSA has been working to identify, assess and disseminate information about programs that can serve as models for adoption or adaptation in communities across the country. Just this past Friday, for example, a program focusing on preventing PTSD among women who had been traumatized previously by sexual assault was given the Department's seal of approval as a prevention program model that works and works well. It is also a model that may have adaptation to the trauma experienced by some children and youth as the result of September ll.

    SAMHSA's Child Traumatic Stress Initiative (CTSI), started in October 2001, provides Federal support to improve treatment and services for children who have experienced trauma; to expand availability and accessibility of effective community services; and to promote better understanding of clinical and research issues relevant to providing effective interventions for children and adolescents exposed to traumatic events. The program supports a network of intervention development and evaluation centers, community treatment and services centers, and the National Center for Child Traumatic Stress. The network was created to help develop and disseminate evidence-based, developmentally-sound assessments, interventions and treatments for children who have experienced trauma; and to work to create a coordinated, national network able to provide services to traumatized children, their families and communities throughout the United States. Specifically in New York, the network includes the North Shore University Hospital's Adolescent Trauma Treatment Development Center, an intervention development and evaluation center, Mount Sinai Hospital's East Harlem Adolescent Traumatic Services Community Practice Center and Safe-Horizon's/Saint Vincent's Child Trauma Center Continuum of Care, community treatment and service centers.

    For nearly 30 years, SAMHSA and its predecessors through its Center for Mental Health Services have worked with the Federal Emergency Management Agency (FEMA) to help administer the Crisis Counseling Assistance and Training Program. These disaster mental health programs work through existing community-based agencies and involve strong partnerships with voluntary agencies, faith-based organizations, schools, and community leaders to provide funding support for mental health services following a disaster. They are implemented at the request of a state or territory when a major disaster has been declared by the President. In the aftermath of the September 11 attacks, this program has funded crisis counseling projects in New York, New Jersey, Connecticut, Massachusetts, and Virginia. In addition, SAMHSA awarded supplemental funds related to the September 11 attacks to all of the States that received FEMA grants as well as to Pennsylvania, Maryland, the District of Columbia, and Rhode Island.

    One of the most important programs that was funded is Project Liberty in New York State, the largest and most complex of the disaster grant programs. Project Liberty, funded by FEMA, started with an Immediate Services Grant of $22.5 million and was recently approved for a Regular Services Grant, beginning June 15, of $132 million. The combination of these two grants will allow services to continue through at least March 2003.

    Outreach to children has taken many forms. According to recent service data, 10% of all services delivered have taken place in school settings, largely through a partnership with the New York City Board of Education. In addition, numerous other agencies, e.g. the Administration for Children's Services (serving the foster care population) and smaller community-based family and children service agencies, are participating in the grant. The NYC Board of Education, under the Immediate Services Grant, was allocated $1 million. $7 million has been applied for and approved under the Regular Services Grant.

    Under the Immediate Services Grant, $1 million was designated to the Administration for Children's Services. The approved application for the Regular Services Grant included $4.9 million Through the additional funding provided under the Regular Services Grant, services to children and adolescents will continue to be expanded.

    Our work continues and will continue. For example, we're planning to undertake a case study focusing on New York City and New York State. We plan to look in the rear-view mirror a bit, to assess what we did right and might need to do better in our response to acts of terror or other disasters. We plan to look at how state and local agencies responded to mental health and drug abuse issues arising immediately following 9/11; what makes for good disaster mental health planning and programming; what impediments perceived or real need to be overcome; and, above all, what worked, and worked well.

    Conclusion

    In conclusion, we appreciate the opportunity to be here today. We appreciate the yeoman's work that has been done here in New York City and across the State in the days, weeks, and now months, following September 11 to help meet the crisis and longer-term mental health needs of the children, parents, grandparents, and caregivers who were affected by the WTC bombings. Without question, what we are learning over and over as we work to heal New York's children is that mental health is as precious as physical health; it is as much a part of our public health imperative as any communicable disease. We look forward to working with you and your colleagues in the Senate to help continue to dispel the fear and misunderstanding about mental illnesses that will help countless New Yorkers reach out for the mental health services that may help restore their health.

    Thank you.

    Below are some common reactions that children and adolescents may display.

    Young Children (1-6 years) School-aged Children (6-11 years) Pre-adolescents and Adolescents (12-18 years)
    Helplessness and passivity; lack of usual responsiveness Feelings of responsibility and guilt Self-consciousness
    Generalized fear Repetitious traumatic play and retelling Life-threatening reenactment
    Heightened arousal and confusion Feeling disturbed by reminders of the event Rebellion at home or school
    Difficulty talking about event; lack of verbalization Nightmares and other sleep disturbances Abrupt shift in relationships
    Difficulty identifying feelings Concerns about safety and preoccupation with danger Depression and social withdrawal
    Nightmares and other sleep disturbances Aggressive behavior and angry outbursts Decline in school performance
    Separation fears and clinging to caregivers Fear of feelings and trauma reactions Trauma-driven acting out, such as with sexual activity and reckless risk taking
    Regressive symptoms (e.g., bedwetting, loss of acquired speech and motor skills) Close attention to parents' anxieties Effort to distance oneself from feelings of shame, guilt, and humiliation
    Inability to understand death as permanent Withdrawal , school avoidance Excessive activity and involvement with others, or retreat from others in order to manage inner turmoil
    Grief related to abandonment by caregiver Worry and concern for others Accident proneness
    Somatic symptoms (e.g., stomach aches, headaches) Somatic symptoms (complaints about bodily aches and pains) Wish for revenge and action-oriented responses to trauma
    Startle response to loud or unusual noises Obvious anxiety and fearfulness Increased self-focusing and withdrawal
    Fussiness, uncharacteristic crying, and neediness Specific trauma-related fears; general fearfulness Sleep and eating disturbances, including nightmares
    Avoidance of or alarm response to specific trauma-related reminders involving sights and physical sensations Regression (behaving like a younger child)  
      Separation anxiety  
      Loss of interest in activities  
      Confusion and inadequate understanding of traumatic events (more evident in play than in discussion)  
      Unclear understanding of death and the causes of "bad" events  
      Giving magical explanations to fill in gaps in understanding  
      Loss of ability to concentrate at school, with lowering of performance  
      "Spacy" or distractible behavior  


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Last revised: June 26, 2002