'Defend Childhood’ to improve access to education and explicitly confront childhood trauma

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Morning Zen Guest Blog Post ~ Daun Kauffman

Millions of injured children whose pleas are not being heard are waiting at the intersection of the “Defending Childhood” Report from the Department of Justice (DOJ) and Congress’s rewrite of “No Child Left Behind” education (ESEA) legislation.

As one part of defending childhood, the children need a pivotal revision when the adults in the Senate and House work to reconcile their differences on ESEA.

While the children wait for help, other education efforts are ineffective.

Defending Childhood

The children’s injuries are captured in a term from neurobiology: “childhood trauma”.

Childhood trauma is not “poverty”.
Sometimes ‘trauma’ and ‘poverty’ are misleadingly used interchangeably. Yet, research shows that more than half of those living in poverty do not experience debilitating trauma. Poverty does have a myriad of impacts on learning to be sure, but they are not necessarily traumatic impacts.  

Childhood trauma is a response of helplessness, of being overwhelmed, even terror, from event(s) some call “Adverse Childhood Experience” (ACE): Physical Abuse, Emotional Abuse, Sexual Abuse, Physical Neglect, Emotional Neglect, Single Parent Home (due to separation, divorce, or incarceration), Household violence, Community violence, Household substance abuse, Household mental illness.

The magnitude is staggering. The DOJ Report described it as an “epidemic” back in 2012. Even earlier, back in 1979, the Surgeon General termed it a “national crisis”.   In spite of the stunning scope, and life altering power, children are still being hurt today. To them it must seem like a never-ending nightmare.

We do know how to help.

Instead, at this particular intersection today, where children attempt to “achieve” in elementary and secondary school classrooms, the nightmare continues, and can often be worsened.

Congressional contact info is linked at the end of this blog, for those who are immediately ready to speak for the children.

Wide Scope:   All Neighborhoods
Public health research
by the CDC reveals devastation that is no respecter of demographics, zip code or socio-economic status.  Specifically, researchers found that even in beautiful suburban San Diego, roughly one-fourth of the mostly middle class, mostly white, working folks with medical insurance had experienced 3 or more ACEs!

The wide scope varies in a shocking range from 22%  to  greater than 45% of children impacted by 3 or more categories of trauma — in many school districts the scope is greater than English Language Learners (ELL) or those with an Individual Education Plan (IEP). In some urban locations (pg. 17 map) the prevalence is greater than ELL and IEP students combined!  Each of those impacts is acknowledged and accommodated and funded.  Not childhood trauma.

Three or more ACEs is significant because experiencing 3 or more ACEs correlates with doubled risk of depression, adolescent pregnancy, lung disease, and liver disease. It triples the risk of alcoholism and STDs.  There is a 5X increase in attempted suicide. It doesn’t just go away. Later, if unaddressed, it results in work absenteeism and lost productivity, measured in billions of dollars. The CDC also found a “strong correlation between the extent of exposure to childhood ACEs and several leading causes of death in adulthood. . .”

 

 

 

Center for Disease Control

 

 

 

Deep Impact:   Life Changing
The deep impact of childhood trauma changes children’s physical brains, and impairs their cognitive and social functioning and ultimately their life trajectories.

The neuroscience is compelling.  Childhood trauma connects directly to education via its toxic stress effects on development of the physical brain.  When children live in a chronic, traumatic state of survival, the unresolved toxic stress damages the function and structure of their still-developing brains. These injuries relate specifically to the prefrontal cortex and academic processes, especially executive function, memory and literacy.

The physiological process also leads kids to distorted perceptions of social cues, which alter their social behaviors in response.  Eminently logical defenses in the midst of trauma (hyper-vigilance, dissociation) become ingrained habits, and then destructive, once the threat is extinguished, but the defense pattern remains.

Neurobiology tells us that for the 22% to 45+% of children who are overwhelmed by a state of chronic, or complex trauma, it is physiologically impossible to learn. “Equal Access” requires significant accommodations.

Without the accommodations leading to equal access, children risk having their traumatic experiences re-triggered and further embedded neurobiologically.

Instead of repair, more damage.

Frontline  Perspective From the Classroom
Schools could be safe and even restorative. Instead, the childhood trauma crisis disrupts all schools at times.

At best, trauma-impacted children are invisible in the data and analyses (Try asking for ACE-adjusted, test data). At worst the data is outright misleading, especially for our understanding of academic results including “standardized test” results. The results are a confused, meaningless “average”, including epidemic numbers of trauma-impacted students in defensive “survival” mode with muted cognition.

Pivotal decisions such as ESEA revisions are then based on these deceptive data.

Preparing individual “Section 504” plans for individual children does not address system-wide needs and is not a practical option, given the scope: millions of students.

A successful education paradigm requires: a) explicit acknowledgement of childhood trauma, b) screening students, c) training teachers and d) creating “safety” across the learning environment.

Screening students can be as simple as using the “ACE score” derived by counselors as part of annual school registration or re-registration. A wide range of other screening measures is available at the National Child Traumatic Stress Network website.

Confronting the learning impacts and the classroom impacts of trauma requires training. The most efficient approach is through teachers, “first responders” in the classroom, who see the children daily. Training must be an on-going requirement to: 1) deliver “safety”, 2) understand complexity of teaching trauma-impacted children, and 3) respond appropriately, including avoiding re-triggering old trauma.

Other crucial investments towards safety include appropriate class-sizes, with limits on trauma-impacted children per classroom.  For example, one teacher alone will struggle to be effective aiding one ‘triggered’ student from among the 10 who have 3+ ACEs, within a classroom of 30 kids, total, who are waiting to be taught. Additionally, dedicated appropriate space for children to de-escalate is needed, as well as on-site counselors; counselors, who build on-going relationships with the children and families in the school community.

“We must not look the other way”
A common sense revision to ESEA.

The intersection of childhood trauma and our educational system is the most accessible entry-point to this horrific national crisis.  Virtually all children in the USA traverse some school every weekday.

Traumatized children lose equal access to education without accommodations.

Further, “Childhood trauma” is the missing, macro factor in education which has been blurring our interpretation of results for all micro programs. Meanwhile, we continue pouring billions into education program “buckets” oblivious to the gaping trauma holes in the bottom.

Now, with the ESEA rewrite, we have a choice to ‘Defend Childhood’, to improve access to education and to bring clarity to results, by explicitly confronting childhood trauma. That, in turn, will lead to more equity in education, and better social and financial productivity for our nation.

Ask your Senators and Representatives to add this crucial factor in their revisions to ESEA.

Click the ‘OpenCongress’ link to get names of your Congress members. Click on individual name and find contact information on right side of screen. Email or call them today, or send them a link to this blog about revising ESEA.

Defending Childhood

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Be sure to follow Daun Kauffman at lucidwitness.com

daun

Daun Kauffman has been teaching in Philadelphia public schools for 14 years. "I live, and work, and worship in the Hunting Park neighborhood of north Philadelphia, with students we’ve served. The Philadelphia Inquirer has described the neighborhood as 'a gritty, drug infested barrio'. Nevertheless, my neighbors and students are steadfast, creative and inspiring in the way they wrestle with many life challenges. They have taught me much." 

Sure, Congress can “fire” SAMHSA Administrator Pam Hyde, but is it the right thing to do?

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Note: This Morning Zen post is part of an ongoing series that is exploring specific areas of H.R. 2646 that will need to be addressed in order to create a mental health bill that reflects the full range of needed services and supports to help those with mental illness thrive in the community.

~ H.R. 2646 (The Murphy Bill) attempts to address a management issue through legislation ~ 

For the past two years, there has been a constant drumbeat from members of Representative Murphy’s committee that the Administrator of SAMHSA had been a major obstacle to getting committee questions answered about how SAMHSA approaches its responsibilities. Read our review of the recent hearing featuring Administrator Hyde testifying in front of the House committee and you will get a good feel for the level of animosity expressed during the hearing. It is clear that there was no love lost on either side.

Unfortunately, this frustration with Administrator Hyde also shapes the structural foundation of H.R. 2646, creating an approach to mental health reform that, while full of claims of how the "broken mental health system" will be fixed with its passage, is woefully out of touch with the complexities of the mental health service delivery system at the local and state level. (Read our detailed analysis here.)

Frustrated as they might be, Congress can’t “fire” Administrator Hyde, as the separation of powers between the executive branch and the legislative branch dictates that while Congress has the authority to investigate and allocate funds, the power to replace senior leadership is the purview of the Executive Branch. However, there is nothing to stop Congress from abolishing the position of the SAMHSA Administrator. No position, no Hyde.

Assistant Secretary position
Here is the language in the bill that will effectively give Administrator Hyde her pink slip (H.R. 2646, page 14, line 12):

  • SEC. 102. TRANSFER OF SAMHSA AUTHORITIES. IN GENERAL.—The Secretary of Health and Human Services shall delegate to the Assistant Secretary all duties and authorities that— as of the day before the date of enactment of this Act, were vested in the Administrator of the Substance Abuse and Mental Health Services Administration; and are not terminated by this Act.

In the recent hearing on H.R. 2646, Congressman Murphy said the creation of the Assistant Secretary position would "elevate [the position] in terms of authority (2:28 mark in the video). However, the job duties of the proposed Assistant Secretary are eerily similar to those of the current Administrator. Attempting to further clarify both the rationale behind the creation of the Assistant Secretary position and plans for SAMHSA as an agency, Representative Collins (NY) stated that "no one is suggesting SAMHSA go out of business, but a rebalancing necessary."

Regardless of where you stand on the effectiveness of SAMHSA Administrator Pamela Hyde, addressing those frustrations by attempting to legislate a management issue is just plain wrong, bad law and bad practice.

It may be wrong, but precedence does exist
In 2006, the mid-term elections were coming, and there was mounting frustration with Secretary of Defense, Donald Rumsfeld. Politicians on both sides of the aisle were using him as political chum, and the calls for his removal were getting louder and louder. But, what could they do? During that tumultuous time, Michael Dorf, then a professor at Cornell University Law School, provided a beautifully concise description of how, with just a bit of sleight of hand, Congress could get rid of Rumsfeld. Dorf included historical context for this type of chicanery, going all the way back to the full-scale sacking of federal judges during the transition in power between John Adams and Thomas Jefferson.

  • "Still, there is a precedent for just this sort of end run. Following the defeat of John Adams and the Federalist Party by Thomas Jefferson and the Republicans in the election of 1800, Adams and the lame-duck Federalist Congress created new federal judgeships, and packed the courts with Federalists before the change in power. After they took office, the Jeffersonians simply abolished the new federal judgeships. With no judgeships to fill, the Federalists ceased to be judges."

Dorf concluded his essay in 2006 by questioning whether or not Congress should use such measures to appease personal frustrations with appointed officials in the Executive Branch.

  • "There's an irony for you. With the nation's security at stake, and with Congressional Democrats and Republicans increasingly united in their displeasure with Rumsfeld's conduct of the war, whether he stays or goes should be anything but a political question."

If the Jeffersonians could do it in 1800, why shouldn’t the architects of  H.R. 2646 do it now?
Building a bill from a frustration about the job performance of the SAMHSA Administrator narrows the lens of objectivity to one of partisanship and personal agenda. Ironically, should this bill see the light of day and pass, by the time it does there will be a new administration and Pam Hyde will have moved on to other, less headache-filled adventures.

The question we need to ask ourselves as advocates, and then ask our elected officials, “Is this the most prudent way to deal with a management issue?”  Do we need an “extreme makeover” because we are frustrated with the SAMHSA Administrator? Is this the way Congress should address frustration with Executive Branch management issues in the future?

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network

Gang abatement? Is it possible that school climate and the conditions for learning could reduce violence?

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Morning Zen Guest Blog Post ~ Kevin Dwyer

Is it possible that teaching social skills – combined with the other conditions for learning (CFL) such as connection and caring - could reduce juvenile delinquency, violence, gang membership and even radical affiliations with groups like white supremacists and jihadists? As yet we don’t know but this may be a logical hypothesis worth testing.  We know from long term research that SEL skills have life-long preventive and positive outcomes.  

A well publicized research article (see: Washington Post, July 17th, also highlighted on the PBS Newshour July 16th, and the NY Times July 24th.) one (Washington Post) titled, “Kindergartners” social skills may predict success” may give credence to looking at such potential longitudinal research outcomes. The researcher, Damon E. Jones[1] of Pennsylvania State University lists the social skills of kindergarteners as a good predictor of very long-term academic and social success. Kindergartners who demonstrated skills (as reported in ratings by teachers) such as empathy, listening, problem solving, cooperation and sharing in kindergarten - and the lack thereof, were followed for two decades looking at graduation rates, police records, reports from parents and self reports. Findings for the 753 subjects, controlling for numerous social/economic, ethnic variables, resulted in findings such as, “children who scored well (high) in social skills were four times as likely to get a college degree…”  These highly social skilled children also were more likely to be full-time employed and less likely to be arrested, whereas those with low social skill ratings were more likely to have lower employment and higher chances of being arrested. This study looked at naturally developed social skill mastery rather than a longitudinal study that involved SEL instruction.  The study does confirm the critical importance of social skill mastery for success. The authors of the study also suggest that the findings can identify early (kindergarten/preschool) students who could benefit from interventions to remediate their social skill deficits and reduce negative long-term outcomes for those children.

Outcome measures for social skill instruction have been shown to be positive in academic and behavioral results, including improved attention span, reading scores, attendance and, yes social skills (see the CASEL.org website).  

So, can SEL instruction and other resilience building CFL methods reduce gang affinity and violence? I don’t know, but there are some studies that imply “Yes.” Take lowered juvenile arrest rates of identified at risk students being lowered by participating a first grade classroom positive behavior game.  The decades long study of the “Good Behavior Game” [2](GBG) showed that this first grade classroom behavior management activity reduced the teenage arrest rate of participating students, who were already identified as having problem behaviors, when compared to similarly identified  students who did not experience this preventative intervention. In other words a simple classroom team structure that enabled first graders to compete at being “good” had a life-long positive impact! The boys in the study identified as behaviorally at risk in first grade were followed throughout their schooling and into adulthood. As young adults, they (males in the study) had significantly fewer arrests for violence than the matched control group that did not participate in the GBG or received added reading support. Further research showed that their drug use was also lower. One might suppose that they were less likely to be violent gang members as well but this was not measured. Other programs build on this strategy and replicated the positive outcomes, particularly for behaviorally troubled males. The GBG is an example of positive discipline and social skill development, and a components of the conditions for learning. The GBG study was a one-year, first grade intervention. Imagine the GBG combined with SEL instruction and other preventive, resilient-building interventions such as those that enhance connection and caring.  

Connection and caring are another condition that frequently is thought of as components of a “safe and effective schools.” Positive, active connection to school through participation in extracurricular activities has been known to significantly improve attendance, graduation and positive behavior.  Class meetings, advisories have also helped ensure connection and caring.

I am unsure if lowered gang membership or radical group affiliation have been outcomes measured in that research. Caring and connection have what we call “face validity” in that it makes sense that students who are known and are cared for (treated with respect and valued) are less likely to seek out affiliation with such radical groups.

Maybe someone is already doing this research. If not the federal government should be funding such important gang, violence and security measures. I would love to hear that we are looking at the long-term impact of connecting with our children and youth and giving them life-long social/emotional success!


References

[1] Damon E. Jones, Mark Greenberg, and Max Crowley.  (2015). Early Social-Emotional Functioning and Public Health: The Relationship Between Kindergarten Social Competence and Future Wellness. American Journal of Public Health. e-View Ahead of Print. doi: 10.2105/AJPH.2015.302630   

[2] The Good Behavior Game and the Future of Prevention and Treatment  Sheppard G. Kellam, M.D.,1 Amelia C. L. Mackenzie, B.S.,1 C. Hendricks Brown, Ph.D.,2 Jeanne M. Poduska, Sc.D.,3 Wei Wang, Ph.D.,4 Hanno Petras, Ph.D.,5 and Holly C. Wilcox, Ph.D.

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dwyerKevin P. Dwyer, M.A., a Nationally Certified School Psychologist, is an education and child mental health consultant. He recently served as a principal research associate for the American Institutes for Research. For over 30 years he practiced school psychology in public schools and held several local, state and national leadership positions in the fields of mental health and education, being responsible for the design, development, implementation and evaluation of programs and practices, for improving school climate, safety, and well being for the education, and mental health of children. He has helped school staff in many districts use data to inform decisions on improving caring and connectedness with students and professional peers.  His work, publications, presentations, and practices have influenced public policy and the development of efficient, family-focused collaborative child service systems. During his 30 years as a public school psychologist, he worked directly with over 10,000 children and their families as well as trained over 6000 educators. He provided psychological services to children, including those with disabilities and those whose anxiety and mental health problems blocked learning and adjustment. He assisted teachers and staff in supporting a caring, inclusive school climate for all children. In 2007, the Maryland Coalition of Families awarded Mr. Dwyer and his wife for their work in making schools more family friendly. He served as president of the National Association of School Psychologist and was given its highest honor, the Life-time Achievement Award. In 2000, he received the Tipper Gore “Advocacy award for improving the lives and mental health of America’s children” from the National Mental Health Association.

Winter Break

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Morning Zen Guest Blog Post ~ Lauren Shapiro ~

It was nine o’clock on Christmas morning, and I was putting on my bathing suit at the Rincón Beach Resort in Puerto Rico when my phone rang.

“Dad’s gone again,” my sister said. “He left another note.”

A tunnel opened up inside my head and began sucking up everything in the room: the torn gift wrap on the floor, the scattered toys, my husband, Kevin, who was struggling to get our one-year-old son into swim trunks.

“What did it say?” I managed.

“That it was no one’s fault.” I hung up and collapsed onto the bed.

“He’s going to do it this time,” I said, the tears coming on now.

Kevin paced the room. “The fuck were they thinking, calling you?” he yelled. He picked up his phone and began to text my sister.

“Stop, stop, stop,” I said, burrowing in deeper. The room was the tunnel, and I was part of it. The boundaries of objects evaporated.

 “We’re two thousand miles away! It’s Christmas!” he said. “What the fuck do they want you to do? Sit and cry in a hotel room?”

“He’s doing it,” I said. “I know!”

“No, he’s not. He doesn’t have the balls.”

I was suddenly aware of our son, Javi, half dressed and clutching a pacifier in each hand, staring at us. Had I ever cried in front of him? I wiped my face.

Because there was nothing else to do, we went down to the pool.

***

Our friends Dan and Becca, just married, had joined us for Christmas, along with my in-laws, who live in Puerto Rico. Kevin’s parents had divorced, but the birth of Javi, their only child’s son, seemed to have brought them closer together. The resort was small, a hotel really, but the pool sat right next to the beach and featured a small and very infrequently staffed bar. There was a kiddy pool, a hot tub, a giant chess board, a ping-pong table without paddles.

The place was almost empty, save for another family that I recognized from yesterday. Kevin had pointed out their little girl, roughly four years old, who’d refused to let Javi play with her toys. “That girl will grow up to be what we call a comemierda,” he’d said, “a spoiled brat. Just look at her.” She was dressed similarly today: a sparkly pink bathing suit, matching water shoes, elaborate hair bows, a glittery star sticker stuck to her cheek. And she was surrounded by intricate water toys: boats with removable plastic people and doors that opened and shut, large dolphins and whales that squeaked and spouted water, a floating island with palm trees and a treasure chest. I set Javi down next to his own paltry selection: a cheap plastic boat, a few squirt toys. He immediately went for the girl’s dolphin.

“Mami, no! It’s mine! He can’t play with it!” the girl whined in Spanish, looking at her mother and pointing at my son. My phone rang. I let Kevin deal with Javi.

***

“He’s alive,” my sister said matter-of-factly. “Dan found him on a ledge at the top of the Air Rights Garage. He pulled him in and held him until the police arrived.”

I pictured my slender twenty-six-year-old brother dragging our father over the concrete divide of the garage and pinning him to the asphalt. Less than a month before, on his previous attempt, my father had gone to that very same spot. He’d left a note at home then, too, and while Kevin and I and the police raced around New Haven—looking for his car, trying to track his phone, texting and calling him endlessly—he was trying to find places from which to jump: the bridge (under construction), an icy lake, and finally the ten-flight Air Rights Garage. After nearly six hours, something—I can’t imagine what—must have clicked off in his mind, and he turned the key in his car’s ignition and descended the ramps out of the garage. When he got home, he stumbled out of the car with a Ziploc bag in his right hand, his wallet sealed inside it. He’d be committed to the very hospital where he worked as a pediatrician. They’d only keep him for three nights.

Kevin and I had just moved from Madison, Wisconsin, to Hartford, Connecticut, and it was a move I was beginning to regret. After a few difficult months of living with my parents, we’d rushed into buying a house we couldn’t afford; Javi was not taking well to daycare; and I was busy teaching at a local college and working through the final edits on my first book. Our move to Hartford had been influenced, in part, by the idea of being closer to my parents after Javi’s birth. But distance had perhaps led me to minimize the depths of their issues with mental illness, and I soon found myself thrust suddenly into this caretaker role, striving as best I could to bring an elusive happiness and order to their complicated psyches. My siblings, both of whom live in California (“I wonder why!” Kevin would joke), had come to Connecticut for the holidays so we could take a break. For the past five months, I’d been looking forward to nothing more than sitting on the beach and reading gossip magazines, of playing with Javi in the sand, of sipping piña coladas with our friends.

Dan came on the phone and related today’s scene: “I snuck up behind him and just bear-hugged him, started yelling, ‘Dad, it’s me, Dan!’ He tried to unzip his jacket. He told me to let go, that he’d come back in. I was like, ‘Are you fucking kidding me?’ I don’t know how, but I just pulled him over and started yelling for the police, who were on the ground. I just held him until they came up.” He was breathless, pumped.

“Are you all right?” I asked.

Me?” he said. “Are you kidding? I’m a fucking rock. I’m fine.”

***

By the time I got back to the pool, the little girl had moved all of her toys back up to her lounge chair, and Javi was paddling around with Kevin. Our friends were in the pool as well, along with Kevin’s mother. His father had come down from his room and was parked at the bar, smoking a cigarette. The bartender, as usual, was nowhere to be found.

“Hello?” Kevin’s father yelled. “Anybody? Should I just get behind there and make myself a drink?”

Eventually a young man sidled in behind the bar and nodded.

“Cuba libre,” Kevin’s father said.

It started to rain. I sat beside him at the bar and ordered a scotch on the rocks.

***

The mother of a close friend of mine had been diagnosed the previous week with Parkinson’s disease, and another friend’s father had recently entered hospice with a terminal case of colon cancer. These were terrible illnesses, the parent wasting away, not wanting to go. Despite the emotional toll this must take, it seemed to me an uncomplicated kind of mourning—two people wrested away by a body’s breakdown. People offered public condolences, posted on Facebook. I had told next to no one about what was happening to my family, what had been slowly and painfully happening for months and months, during which I had been desperate to fix things. I brought my son to see my father at every opportunity, called my father’s psychologists and psychiatrists with worried anecdotes, confronted my mother about her needy behavior, scanned lengthy articles on the Internet, planned elaborate family trips we all knew would never happen. If my father had been diagnosed with a physical illness, even a terminal one, I could have accepted it, been open with people about it.

Instead, I took his recovery onto myself, feeling acutely and privately responsible. If only I did this, if only I did that. Was he in a slightly better mood today? Could I somehow get my infant son to lift his spirits? It was a never-ending dance, an impossible choreography, and he wasn’t even looking. Month after month, my father had wanted to die, had been obsessed with it, but he was still here—wasn’t he? “You kids kept him alive,” my mother had said. “You’re the reason he couldn’t bring himself to do it.” But was this a blessing or a curse? Had we been his saviors, or had we been some kind of tragic impediment, willing him to remain alive in endless, guilty misery?

My father had been the oldest of five, but only three were left. One of my uncles had been schizophrenic and off his medication, and had asphyxiated himself with a plastic bag in his early twenties. Terrible as this was, there was a medical explanation, a diagnosed illness with a name and an appropriate course of action that had not, tragically, been followed. Another uncle, Danny, had fallen prey to a more complicated depressive illness. Afterward, they’d found lists—pages and pages long—of everything he’d felt he needed to accomplish in a given day. Clearly, there was a deep obsessive streak, perhaps OCD, like my father suffered from. Danny had apparently paced back and forth on a bridge in San Francisco for hours before throwing himself off, landing on a red playground slide below.

In both cases my grandfather had visited his sons several days before their deaths, assuring everyone when he left that they were fine. How is this lack of awareness possible? Had my grandfather done all he could? Had he unknowingly pressured his sons into feigning health? There is something mystical about the force of positive thinking, that dull beacon of hope that gets people through difficult times. On the flip side is the blade, the willful ignorance that keeps someone from seeing the terrible reality in front of them.

***

After his second suicide attempt, my father was diagnosed with a severe form of agitated depression that had been worsened by the high dosage of Prozac he was taking. He’d padlocked his computer in an attempt to keep the CIA away from his investment information, and he was convinced that the American Medical Association was on the brink of revoking his medical license because he’d written himself a prescription, left unfilled, for tranquilizers. My mother caught him looking at website articles with names like “How many Tylenol does it take to kill yourself?” and “How to commit suicide but make it look like an accident,” which prompted one of many phone calls to his doctors. My parents had been having serious relationship issues after my mother’s own semi-breakdown seven months earlier. On Father’s Day, two weeks before Kevin, Javi, and I were supposed to move in with them (and as we searched for more permanent lodging), she’d sent a rambling, incoherent email to us, her children, explaining that her marriage was a sham and that she had taken enough pills to kill herself. When I couldn’t reach her, I called 911; the police found her hiding in my father’s room. My father was on vacation in Turkey with my brother, and when I Skyped with them to tell them that Mom had been taken to the ER, they appeared onscreen in a cave à la Osama bin Laden hideout. Stalactites dripped in the dim background of the screen, and my father’s bearded face hovered in the abyss.

“Jesus, where are you?” I asked.

“In a cave hotel in Cappadocia—asleep,” he said.

“Did you get my email?” I said quickly. “Mom’s on her way to the ER.”

There was a pause. “What do you want me to do about it?” he said flatly. “You know she’s always creating drama.”

I was stunned. What did I want him to do about it? I guessed I wanted him to come home immediately, as I was living halfway across the country with a six-month-old, a job, a house to sell, and a move to prepare for. They did come home, of course, and indeed it all turned out to be a hysterical, desperate plea for attention on my mother’s part. The damage had been done, though—my father slipped into a deep depression as he sifted through the wreckage of his perennially unhealthy marriage, the loss of his brothers, his dwindling place at work, his lack of future prospects.

***

What was going through my father’s head in the months of deep depression and despair before his suicide attempts? What had led him to leave the hospital the first time, assuring everyone he was fine, all the while planning a second attempt? He had emailed my mother, the first time, a one-liner that said, simply, “Look in the bag behind the computer.” There my mother found a brief suicide note that my father later admitted to having put there months before. How had he gone about his days, seeing patients, getting dinner with us, playing hollowly with my son, all the while desperately hatching these plans? I can’t know what my father was feeling, but it must have been comprised of blinding terror, guilt, self-hatred and wells of despair I can’t begin to fathom. Whatever it was had taken him not only from us, his family, but also from himself.

***

My father has never been one to discuss more than pleasantries and mundane daily details, even with his children. He will chide me for not maintaining adequate records for tax write-offs or ask what my son has done that day. If you try to ask him a question—about work, about how he’s feeling—the answer is always “fine.” Once, though, a few years ago, he was driving me back to the airport at the end of a visit so I could fly back to graduate school. The air had been mostly dead, the car silent for much of the drive, neither of us offering much, as was our way.

Suddenly he said, “You know, I’ve carried a lot of guilt since my brothers’ deaths.”

We were two minutes from the airport, and in the shock of the moment, all I could do was offer a generic remark.

“Even though it’s not your fault, it must be really hard to live with that.”

We pulled up to the terminal, and I got out of the car. I was shocked by my father’s sudden admission, so unlike him. He’d recently started therapy, so I guessed that this must have been one of the first things they’d talked about. But as I sat at the gate, rethinking everything I could have said, I became irritated. Why had he chosen that moment to delve into such deep psychological terrain when I’d been visiting for two weeks? In retrospect, could I have done something then to steer him on a different path? Maybe this had been his way of beginning to crack through his wall of pleasantries, the artificial bubble that seemed to envelop him wherever he went: I’m fine, that almost religious family refrain.

***

I spent Christmas afternoon getting drunk on the beach in the rain as my husband and our friends gingerly followed suit. My mother-in-law had taken our son in for his nap, and Kevin’s father had gone to his room. After my fifth scotch, things didn’t seem less dreary or strange, but I was laughing a little wildly now.

“Hey guys, look at that couple—they must be on their honeymoon—how cliché!” I said loudly, pointing to a guy and girl in their twenties who had buried each other in the sand. “There goes the comemierda!” I said, as the family with the little girl packed up their things, looking at us strangely.

“Shhh,” Kevin said. “Hey, maybe you should slow down a little?”

“Why? It’s fucking Christmas. We’re on a tropical island. Didn’t we come here to have fun? What’s wrong with you guys?” I said. “Another round?” Our friends were smiling a bit nervously, clearly caught in something they hadn’t bargained for.

“I might just have a water,” Becca said. “Can I get you one, Lauren?”

“Oh God,” I said. It was all hilarious—Christmas, my family, the tropical paradise, the rain, everyone tiptoeing around me like I was an invalid. “Seriously, guys? Fine, I’ll stop. There’s no service anyway.”

The bartender had indeed disappeared again, and as time passed, my dark humor blanched into a feeling of incredible nothingness. Not numbness, just nothing, anywhere, for miles around. My phone lay silent as well.

Any holiday in Puerto Rico is a good occasion for fireworks, apparently. That night at the Rincón Beach Resort, the sky came alive with them, like small explosions of mercy. Because we were on the sparsely inhabited west coast, absent were the familiar honking and screaming we would have heard in my mother-in-law’s condo just outside of San Juan. We were secluded, incubated in an alternate tropical world that sent out streaking flames of celebration everywhere I turned. He’s alive! He’s alive! He’s alive!they seemed to say, over and over, so that the phrase eventually lost all its meaning and became just a wave among the others, lapping up to the deserted beach.

* * * * *

Lauren Shapiro is the author of one of the essays in the book Writing Away the Stigma.

Brain development, brain injury and childhood mental health

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Morning Zen Guest Blog Post ~ Rahmi Elahjji ~

In 1999, the New York Times covered (what is now understood to be) a landmark study by Dr. Antonio Damasio on how early childhood brain injuries contribute to the expression of abnormal behavior, inappropriate emotional responses and impaired social skills. Dr. Damasio and his team studied two individuals, both of whom sustained brain damage by accidents or disease early in life. Both individuals had significant problems adjusting to normal life: they had trouble following rules and planning for the future; they could not express normal emotions of guilt, remorse, or empathy; and they engaged in risk-prone behavior throughout adolescence and early adulthood.

Dr. Damasio's study did much for expanding how brain injuries can affect mental and behavioral health throughout adolescence and adulthood. However, research about what effects childhood brain injuries have on children's emotional and behavioral development is still limited. In the studies that have been conducted, the research suggests that the incidence of early childhood brain injuries, depending on their severity, strongly correlates with the onset of emotional and behavioral issues in adolescents and adults.

Children form a specific subset of the greater population who are most at risk for acquiring brain injuries. More specifically, children from disadvantaged backgrounds are especially at risk. Children are also the most likely to experience the long-term consequences of brain injury. Damage to the brain in the critical early stages of development can have serious consequences on processes like emotion, memory, decision-making and self-awareness.

For most parents, brain injuries are most associated with sports concussions, yet brain injuries with similarly significant consequences can come in many other forms, including:

  • Infection that results in high fever
  • Drowning
  • Loss of oxygen (asphyxiation, hypoxia)
  • Pediatric stroke
  • Shaken Baby Syndrome
  • Falls as an infant or toddler
  • Blows or external wounds to the head
  • Use of addictive substances
  • Resected brain tumors

For more resources on the risk of brain injury in children:

New research also suggests that the most prominent risks of brain injury differ among different age groups of children. Toddlers and younger children are more likely to experience brain injuries as the result of falls, while adolescents and teenagers are more likely to experience them as a result of sports concussions or motor vehicle accidents.

The risks of brain injury, especially among children, have recently evolved into a major public health concern, making a marked presence in multiple policy arenas. The state of Texas for example, instituted a comprehensive program in 2012 for reentry into school for students with brain injury. Attention at the national level has generated a traumatic brain injury imitative within the U.S. Department of Health and Human Services with a substantial amount of federal funding.

In preventing the most harmful consequences of brain injury, early identification and treatment is absolutely crucial. Parents should be vigilant for signs of mental, behavioral or emotional changes after their children sustain an injury to the head. These signs could manifest as any one of the following:

  • Difficulty concentrating or maintaining focus
  • Limited attention span
  • Consistent mood swings, without apparent cause
  • Increased anxiety or irritability
  • Risk-prone behavior
  • Difficulty planning or prioritizing
  • Inappropriate or inconsistent emotional responses to events in their surroundings
  • Decreased "social awareness" - trouble interpreting the actions, emotions, and behaviors of others
  • Challenges with speech production and comprehension
  • Occasional dizziness, or lack of balance

For more information on the signs and symptoms of a potential brain injury in children:

The challenge for parents is in trying to figure out which of these signs might be attributed to a possible brain injury and which might be attributed to normal developmental changes in childhood or adolescence. Something like consistent mood swings, for example, could be caused by a previous brain injury, but they could also be caused by normal emotional changes during early adolescence.

This is why it's important for parents who suspect that their child or teenager is exhibiting these emotional or behavioral changes as a result of some kind of brain injury consult their doctor, who will be able to perform neuropsychological tests as part of a wider assessment of mental and behavioral health.

Of course, the most obvious thing that can be done is to try to prevent brain injuries from happening in the first place. Although the risk of brain injury for children can never be outright eliminated, meaningful steps can be taken to mitigate that risk:

  • Wear a helmet when riding bicycles, skateboarding, roller boarding, skiing as well as other outdoor activities
  • Always wear a seatbelt as well as a car seat when appropriate
  • Follow proper protocol for concussions prevention and management during contact sports like football and hockey
  • Follow posted rules for swimming in pools and beaches; avoid head-first diving at low water depths

While the research is still unfinished on the nature of the relationship between brain injuries and mental health, we at least know that one exists. The upshot of more effective prevention and identification programs for brain injuries is that they lead to better treatment outcomes, improved mental health and a vastly increased overall quality of life.

For comprehensive information on childhood brain injury prevention, diagnosis and treatment:

rahmiRahmi Elahjji is a summer intern in the Office of Acquired Brain Injury at the Texas Health and Human Services Commission in Austin, Texas. The Office of Acquired Brain Injury is the primary Texas agency that provides service referral and coordination, guidance and consultation for individuals living with brain injury and their families; it also supports brain injury prevention and awareness efforts throughout Texas. Rahmi is currently a junior at Washington University in St. Louis, where he is double majoring in History and Cognitive Neuroscience. He is especially interested in how far brain research has come and how far it has to go. He is excited for the possibility of the latest advancements in research translating to better health and improved quality of life for all communities. Rahmi is originally from San Antonio, Texas.

Blood Work

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Morning Zen Guest Blog Post ~ Yona Harvey ~

I lock my office door, take a few deep breaths, and turn the pages of Brandi’s journal. It’s the fullest personal record of my sister’s life, the only one I found while cleaning and packing her Chicago condominium. I’d recognized it immediately by the Jacob Lawrence painting, The Library, reproduced on the front and back covers. I’d given Brandi the journal to celebrate her first birthday away at college. When I found it, our parents were packing up in other rooms, and I quickly shoved it into my purse. Brandi would not, I convinced myself, have wanted our parents reading her journal. Besides, what if she’d written something critical of them? They wouldn’t be able to handle it.

Mostly the journal is an account of Brandi’s first year on campus at The Ohio State University, filled with predictable gripes about classes, dorm mates, and new love interests. Her journal also reveals, though, bouts of depression, stress, insecurity, and suicidal thoughts, as well as her visits to a campus therapist. The 1994–1995 academic year was a challenging period for my sister. It was her first time away from home, and she was baffled by the social life, contradictions, and new ideas that many college students face. Not long after Thanksgiving 1995, she writes:

Good Things

  • M. looks up to me—school—change[d] her major to business (accounting)
  • R. looks up to me—I encouraged her to stay in college
  • Yona looks up to me—personality
  • My family looks up to me, i.e. college
  • M. loves me
    His family loves me
  • L. loves me
    His family loves me
  • Granny loves me
  • Think about D.J.
  • L.E.

I believe Langston Hughes when he writes that “poems, like prayers, possess power,” and I read what Brandi writes as a poem. Brandi’s poem has a title, line breaks, and an affirming catalog of “good things” that ends with the name of a teenaged boy, L.E., who once captured Brandi’s imagination. Maybe because I’m a poet and an older sister wanting peace of mind, I can’t help but read Brandi’s work this way. I want to believe that Brandi’s catalog of good things pulled her back from isolation. And I’m relieved to know that, for one year at least, Brandi found some comfort in writing and recording her thoughts, and that she sought help for her depression and difficulties. What she writes is part poem, part affirmation, part girl talk, and part secret. And, like Brandi, the poem keeps certain information to itself. Who, for instance, was D.J.? The name doesn’t ring the slightest bell.

Her sloppy handwriting and cryptic, graffiti-like tags—“college life,” “snap,” “fuck da bullshit”—make me feel connected to Brandi once more, binding us together again as two sisters who gossiped and vented in my high school bedroom with the door shut. But the journal also makes me wonder why Brandi never told me about feeling depressed. She was my most trusted friend, the maid of honor at my wedding, my closest living ancestor. Did she feel ashamed of her depression or the inner workings of her brain? Did my parents and I pressure Brandi with too many expectations? If I hadn’t become distracted by the demands of marriage and mothering, would Brandi have called me for help sooner—long before she found herself running from an ER examination room to peer over the ledge of a hospital garage roof?

“Sometimes I think I’m slow,” she writes on one page of her journal, as if people were born hip and charming, as if the young women and men around her were pulling things off better. She didn’t hide what she didn’t know; she was incapable of such posturing. What she didn’t know, though, sometimes embarrassed her.

Reading the journal, I search for the one clue that will erase all mystery, the sentence that says, “On this day, at this time, such and such happened and put me over the edge.” I look for any hint that predicts how Brandi might have felt during the last week of her life. And when I can’t find helpful clues from that period, I hunt further back, trying to locate some revealing thing about the way my sister and I grew up, how we lived, who we befriended, what we ate—anything that might help me to understand Brandi’s anguish. I can never dissect Brandi’s brain, examine her body, or take blood samples. And Brandi’s journal is a fragmented record, with time gaps. Her entire adulthood is missing. Brandi was thirty years old when she died—far from the freshman college student who wrote these pages. Perhaps my clinging to these pages makes no sense. But as the sound of Brandi’s voice, her scent, and the tightness of her hugs fade, these tactile pages remain. Years past Brandi’s death, I’m relying primarily on memory; but turning the pages, I commit to the difficult work of unearthing the mysteries of my sister, my kin, my blood.

***

It’s early April 2007 in Cincinnati, Ohio, a few days after Easter. It’s the season of children’s recitations of Bible verses, family dinners with glazed hams and green beans with potatoes, ritual prayers by the faithful for the sick and shut-in. Sinners who’ve drifted return home to Zion for the pastor’s retelling of Christ’s resurrection, that quintessential Christian sermon. My mother, recently retired as a secretary from Proctor & Gamble, has become an ordained Pentecostal minister. And though she doesn’t yet know it, this week will mark the beginning of the insomnia that will plague her for the next several years.

“I’m stressed out,” Brandi will often say before growing silent, starting to weep, or falling to the living room floor of our parents’ condominium to pound the carpet with her fists. When my parents and I ask, “What’s wrong?” this is always her sole explanation. When she isn’t crying or curled in a heap, she wanders from room to room with a distant look on her face. She breaks her silences with what appear to be newly surfaced memories, rattling off time-warped sentences like a broken doll with a worn and tangled string on her back. “You need to learn to love yourself,” she says, grabbing and shaking the bedpost in our parents’ room. “You need to learn to love yourself,” she repeats, mimicking, it seems, someone else’s harsh criticism. Or, perhaps, her own?

Her shiny black hair is wound in two-strand twists, slightly frayed at the ends. She’s dressed in a T-shirt and sweatpants; anyone might mistake her for a college undergraduate. With the exception of her hair, which she changes frequently, Brandi looks the same as when our mother saw her last: she has the clear, amber skin of a person who doesn’t drink, smoke, or eat much junk food. Before walking away, she stops, turns, and faces our mother.

“Did he put his hands on you?”

Her question bears a startling mystery and soundness. Did who put his hands on her? Brandi resumes her meandering without waiting for an answer.

Our mother follows Brandi from room to room; and after several hours, she calls me. “She won’t calm down,” she says, shortly after midnight, whispering into the phone so Brandi won’t overhear. “She doesn’t want to be alone, and she doesn’t want me to run any water.”

***

“Chicago is not my home,” Brandi says, correcting the ER nurse who reviews her insurance and contact information. This morning, our mother gave Brandi a bath and brushed her hair, just as she’d done when Brandi was little. Brandi hasn’t slept much, but she is calm and waits quietly for her assigned doctor. In her medical records, we will later see, the nurse describes Brandi’s voice as despondent and “flat,” noting that the patient says she is “stressed.” He directs Brandi and our parents to the seating area.

The Christ Hospital is where our parents met as teenagers, earning their first real-world paychecks by delivering food trays to patients. Granny, my father’s mother, retired from food service here and lives a few blocks away. The hospital rests in the heart of Mount Auburn, a neglected, predominantly black neighborhood that was once the home of William Howard Taft. In recent years, white city residents searching for cheap property near the University of Cincinnati have ventured as far as Granny’s street, the first signs of inevitable gentrification.

After a few hours, the nurse calls Brandi’s name and takes her to the examination room, our parents following softly behind.

“If you don’t want to be here,” the nurse says, handing Brandi a paper, “you can complete this form and be released.” Brandi writes her name, then hesitates. She crumples the paper.

The doctor will introduce himself and seem, my parents will say, slightly bothered by what he assesses as Brandi’s lack of cooperation. Does the doctor have any experience with mentally ill patients? Do the doctor’s questions about physical ailments reflect his inattention to Brandi’s mental health? Does the doctor find it strange that my parents have accompanied their thirty-year-old daughter to the ER? Does the white doctor have prejudices about the black population of Mount Auburn? If so, to what degree are these prejudices at work? Does the doctor believe mentally ill patients have a certain physical appearance? That they speak a certain way? Behave a certain way? Should attending ER physicians have a list of questions that address mental health care? These are some of the questions I’ll formulate during the next several months. These are the questions I’ve asked again and again and again. And each day without Brandi I answer: yes, yes, yes.

Here’s what will be undisputed: The doctor’s phone will ring. He’ll take the call and leave the room.

After a while, Brandi will fidget; she’ll ask if the doctor will be back soon.

And then, the action that will puzzle and haunt everyone forever: Brandi will run. She will run like an Olympic medal is within her grasp, like her legs are made of bionic parts, like the Hellhounds are on her trail. A knees-up, pumped-up bolt.

The thirty-something doctor with wire-rimmed glasses and thinning blonde hair will return to my mother to ask if our family has any history of mental health issues. His question will be too late.

***

Brandi is throwing a housewarming party at her condo on Chicago’s South Side; my mother, father, grandmother, and I arrive a day early to spend more time with her. Though my sister bought her condo over a year ago, her rooms have few accessories and no paintings or pictures on the still-white walls. Her furniture consists of a small kitchen table, a modest sofa, a few chairs. Our footsteps echo as we walk along the hardwood floors.

Brandi’s condo is the exact opposite of my home in Pittsburgh, where I trip over toys, cram books and magazines into corners, and greet another person in every room. My attention bounces precipitously among my husband, Terrance; my three-year-old son; my seven-year-old daughter; an unfinished poetry manuscript; and an intense graduate program in library and information science. Brandi and I share the nasty habit of doing too much at once. So I feel relieved to be simply a sister and daughter again, however briefly. I suspect Brandi feels this relief, too. Her friend who was supposed to help with party planning cancels at the last minute, and Brandi instantly puts my mother and me to work. We land at Target, searching for napkins, paper plates, and air mattresses, and despite the upcoming party tomorrow, we easily fall back into our familiar, carefree disregard for time.

“What do you think about these pants?” I ask Brandi.

She turns up her nose. “I don’t buy clothes at Target.”

“Forget you,” I say, fake-elbowing her. “Married mothers of two on a budget shop at Target.” I can hardly stop smiling. I’m proud of Brandi, all grown up and living what I perceive to be a “cool, single life” in the big city, a funds manager at Northern Trust Bank who has modeled in hair shows for neighborhood salons. She has new friends from her church and job, some of whom will attend the party. A few co-workers have been trying to fix Brandi up with “the new guy” from the UK, but she’s not interested. He, too, will be at the party, and I’m eager to size him up.

Back home, I’m swimming to stay afloat and maintain an independent identity, which seems to multiply with each commitment, childbirth, and family move. Maybe this is why I can’t see Brandi’s loneliness. I often long to be alone, taking for granted the built-in support around me—my son’s fingers curled around my hair, my daughter’s framed artwork, Terrance’s affections—human touches. I do not imagine how strange it might be for Brandi to hear only the echo of her own footsteps and, perhaps, the murmur of television voices at the end of the day.

***

I’m speeding south on Interstate 71, passing the city limits of Columbus, Ohio, the last segment of the drive to Cincinnati from my house in Pittsburgh. I feel the air leave the car, the swift pressure of a tight squeeze around my arms and chest, and then the ghost thump of drums. Why can’t I breathe? Joan Osborne slips through the stereo speakers with her blues brand of Bob Dylan’s “Man in the Long Black Coat”: “she’s gone, she’s gone.” Only a moment ago, at the side of the road, I played a voicemail message from Aunt Nellie, my mother’s sister.

“Come to Christ Hospital,” she said. “Get here as soon as you can.”

She didn’t answer when I called back. Why was she calling me when she knew I was already on my way to meet Brandi and my parents? And why am I even listening to this music? At the last minute, I grabbed the CD from an old box of forgotten discs, not wanting to waste time, having no memory of this song or its lyrics. Did I tune out Brandi in a similar way? Hearing only what I wanted? Hearing only what felt neat and good?

I was up most of the night, the result of my mother calling every two hours or so in a panic about Brandi, whose behavior has become increasingly erratic this past week.

“I’m afraid of who’s waiting there,” I told Terrance a few hours ago, placing my toothbrush on the bathroom counter. He stood behind me, wearing his glasses, his six-foot-six, former-college-basketball-player body barely fitting the mirror’s frame.

“It’s gonna be fine,” he said, rubbing my shoulders. “And it’s not about you; it’s about your family. They need you.” But he wasn’t familiar with the Brandi of late, the inconsolable one. He hadn’t heard Brandi’s voice, high-pitched and euphoric one minute, flat and emotionless the next. He knew Brandi as he last saw her: five foot eight and bubbly, Halle Berry haircut, blasting Fantasia songs on her laptop, modeling the winter coat our parents gave her for Christmas, a complete ham sandwich as she mocked the catwalk swag of a high-profile, high-fashion diva.

“OK, love you, bye,” she’d said on the phone, yesterday afternoon, like an automaton asking a customer to hold for the next available agent. It would be the last time I’d hear her speak.

***

No one will catch Brandi. Not the medical staff, not the baffled onlookers, not the team of security personnel, and not my father, for whom Brandi breaks stride for just a second, near an exit that leads to the parking garage roof. “You said they would help me,” she shouts, before turning and running away.

What is the language of anguish? What did Brandi mean when she confessed she felt “slow”? What happened to Brandi during the time when she wasn’t writing, in the years between college graduation and her work for a major banking company? What happens when a woman struggles to find words for the strangeness of her mind? When Brandi told our parents, her co-workers, the emergency room personnel, and me that she was “stressed,” so much depended upon what each of us could hear.

“She jumped on that ledge so fast,” my father will tell me days before the funeral, “like Superwoman. Before she went over, her coat brushed my hand.”

* * * * *

Yona Harvey is the author of one of the essays in the book Writing Away the Stigma.

The 'Murphy bill' (H.R. 2646) fails its own home inspection

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When I printed out the text of the Helping Families in Mental Health Crisis Act of 2015, H.R. 2646 (all 173 pages of it) I had to fight the temptation to jump to the particular areas of most interest to me (AOT, HIPAA, among others) and instead, read it the way you would read a novel, from beginning to end, no skipping ahead to look for the good parts, just one page at a time. I encourage all of you to do the same. If you do, you will get a better sense of the tone of the bill, the overall direction of the bill. In effect, you get a feeling for the foundation that the bill is built upon, and it is the foundation that is most critical to the success or failure of any legislative proposal.

Operating from good intentions
It is important to underscore that Congressman Murphy and the architects of the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646) are working with the best of intentions. I have had the honor of meeting with the Congressman, and there is no doubt that he cares deeply about this issue. The tragedy at Sandy Hook propelled him to take on mental health reform as a defining issue for his legacy in Congress, and for that, one must applaud him. Members of his staff were incredibly helpful to us early on in our dialogue series by encouraging us to meet with and talk to some of their most ardent supporters. We welcomed the opportunity and after meeting their suggested contacts, have developed some enduring friendships and mutual respect.

Developing relationships with ardent supporters of the Murphy bill underscores the importance of “getting it right” when it comes to the language in this bill. Their stories, along with the stories of the equally passionate individuals who have come out in opposition to the Murphy bill, require us to be vigilant in our assessment. We must analyze it far beyond the sound bytes of political expediency so that both supporters and detractors of the Murphy bill can see movement toward comprehensive mental health reform. Here is the little secret about "divisiveness" between mental health advocates that politicians don’t want you to know. When you get advocates in a room together, away from the political spotlight, more often than not, they are in agreement about the need for a spectrum of mental health supports and services, not one end of the continuum versus the other. We need federal mental health reform legislation to reflect that same continuum approach at the state, tribal and local level.

This bill, as currently written, does not do that. However, don't be deterred, Network faithful. In this post, I will discuss several serious issues with the bill. Make no mistake, while there is plenty that is wrong with the bill, this is also the time for us to rally and share our ideas for how to make the bill better. Take solace in the fact that in a recent meeting between family organization leaders and Congressman Murphy, he was quoted as saying that "this is the time to send in language for improvement." Let's take him up on his offer!

Now is the time to get involved in this discussion. Share your ideas for improvement, and together, we can make this a stronger bill that can lead the way to meaningful mental health reform in America.

Warning: I am forceful in my commentary on the bill. I do so, because, as it is currently written, everyone loses. Network faithful who are Murphy bill supporters lose. Network faithful who are Murphy bill opponents lose. Consider my blunt critique a wake-up call to all of us. What we at the Children's Mental Health Network know better than most is that both supporters and opponents of the Murphy bill need to win if we are going to achieve meaningful mental health reform in America.

Let the tough love begin.

Two “wrongs” don’t make a “right”
The Murphy bill rings the bell loudly on SAMHSA’s apparent mission drift away from its legislative required focus on mental illness. On this point, we wholeheartedly agree. It is heartbreaking to hear from so many families with young children who are seriously ill and plead for increased federal focus on the needs of their children with mental illness and the families who care for them. However, the dramatic pendulum shift toward brain research and psychotropic medication to the exclusion of recovery supports is no more “right” than the swing toward “recovery” that gradually gained popularity after the Alcohol, Drug Abuse, and Mental Health Administration (ADAMAHA) was reorganized and became SAMHSA in 1992. In the recent hearing on H.R. 2646, Representative Collins (NY) stated that "no one is suggesting SAMHSA go out of business, but a rebalancing necessary." Unfortunately, this bill is anything but balanced.

The language of hope is abandoned
This bill abandons the language of ‘hope’ and retreats to an earlier time in our history, where we only spoke in the language of ‘disorder’. It would be a shame to see the progress made to de-stigmatize language and provide a sense of hope to those with mental illness wiped away with the stroke of a pen.

A change in the order of emphasis in the preamble of the bill would help
Speaking of language, one instant fix that would go a long way toward reflecting the thinking of communities across the nation in the year 2015 would be to change the order of priority in the opening sentence. The bill opens with the following sentence (Page 1):

  • To make available needed psychiatric, psychological, and supportive services for individuals with mental illness and families in mental health crisis, and for other purposes.

If the architects of this bill granted me the wish to change only one thing in the bill, I would change the order of emphasis of this sentence so that it read:

  • To make available needed supportive, psychological, and psychiatric services for individuals with mental illness and families in mental health crisis, and for other purposes.

A subtle, yet powerful change that would act as a moral compass for all of the language that follows in the bill. Changing the order of priority focus does not diminish the importance of psychiatric services – just puts them in their proper context.

Peer and family support straight out of the 1990’s playbook
If you are a champion for an approach to mental health care that is consumer, family and youth driven, you will probably not like this new version of the Helping Families in Mental Health Crisis Act of 2015.

Sadly, the definition of peer support in this version of the bill does not reflect the forward thinking that has taken place over the past 15 years in understanding family-driven peer support. We have learned much from families about the importance of having family voice that is entirely independent of “supervision of a licensed mental health or substance use treatment professional” (Page 20, line 18), as written in the bill. The importance of recognizing the independent family voice that supplements peer support positions under the supervision of a mental health provider is crucial.

Youth, family and consumer voice on decision-making bodies a mere token
The lack of understanding about the importance of youth, family and adult consumer involvement in decision-making forums is evident throughout the bill. We have learned much about the importance of increasing youth, family and consumer voice beyond token representation. Addressing the importance of providing the necessary checks and balances in decision-making bodies by increasing "voice" beyond the professional occupations identified in the bill is of critical importance.

The structural integrity of the bill is inherently damaged
It doesn’t matter where you land on any of the critical issues in the bill; be it AOT, the role of consumer advocacy groups, HIPAA, or where SAMHSA places its priorities. The structural integrity needed to facilitate the implementation of strategies in any of these areas of focus, as written in the bill, is inherently flawed, and thus, will result in a damaged bill doomed to increased federal bureaucracy, wasteful spending, and a dangerous precedent of congressional supervision over executive branch activities.

The Murphy bill attempts to address a management issue through legislation
For the past two years, there has been a constant drumbeat from members of Representative Murphy’s committee that the Administrator of SAMHSA had been a major obstacle to getting committee questions answered about how SAMHSA approaches its responsibilities. Read our review of the recent hearing featuring Administrator Hyde testifying in front of the House committee and you will get a good feel for the level of animosity expressed during the hearing. It is clear that there was no love lost on either side.

Frustrated as they might be, Congress can’t “fire” Administrator Hyde, as the separation of powers between the executive branch and the legislative branch dictates that while Congress has the authority to investigate and allocate funds, the power to replace senior leadership is the purview of the Executive Branch. However, there is nothing to stop Congress from abolishing the position of the SAMHSA Administrator. No position, no Hyde.

Assistant Secretary position
Here is the language in the bill that will effectively give Administrator Hyde her pink slip (Page 14, line 12):

  • SEC. 102. TRANSFER OF SAMHSA AUTHORITIES. IN GENERAL.—The Secretary of Health and Human Services shall delegate to the Assistant Secretary all duties and authorities that— as of the day before the date of enactment of this Act, were vested in the Administrator of the Substance Abuse and Mental Health Services Administration; and are not terminated by this Act.

In the recent hearing on H.R. 2646, Congressman Murphy said the creation of the Assistant Secretary position would "elevate [the position] in terms of authority (2:28 mark in the video). However, the job duties of the proposed Assistant Secretary are eerily similar to those of the current Administrator. Attempting to further clarify both the rationale behind the creation of the Assistant Secretary position and plans for SAMHSA as an agency, Representative Collins (NY) stated that "no one is suggesting SAMHSA go out of business, but a rebalancing necessary."

Regardless of where you stand on the effectiveness of SAMHSA Administrator Pamela Hyde, addressing those frustrations by attempting to legislate a management issue is just plain wrong. If members of the committee have a problem with the SAMHSA Administrator, then take it up with the HHS Secretary. The Administrators job performance is a management issue, pure and simple, and should be dealt with as such. Management by legislation is foolhardy, dangerous and a waste of the taxpayers money.

The fact that this strategy is not being discussed openly should send chills up your spine. What if a congressional committee was disenchanted with Francis Collins, head of the National Institutes of Health? Would it be wise for them to create a new position, call it something else, but ostensibly doing what Dr. Collins is doing, so that they could get rid of him? And what of the obvious fiscal and bureaucratic changes inherent with such a move? Do we really want to add more layers of bureaucracy just because we are frustrated with a senior level administrator? Creating a new position (Assistant Secretary) in frustration over the difficulties in working with the current administrator is just plain bad law and bad practice.

The question we need to ask ourselves as advocates, and then ask our elected officials, “Is this the most prudent way to deal with a management issue?”  Do we need an “extreme makeover” because we are frustrated with the SAMHSA Administrator? Is this the way Congress should address frustration with Executive Branch management issues in the future?

A bill that hearkens back to the ‘good old days'
This bill, as currently written, takes us back in time; completely sidestepping the advances in knowledge about the importance of family, consumer and youth involvement as complementary approaches, and sometimes superior, to the advances made in medical science.

The structures, committees and reorganizations suggested in this new version of the Helping Families in Mental Health Crisis Act of 2015 are all designed to funnel through a narrow psychiatric lens that will have a significant impact on the overall direction of federal mental health efforts.

One must be careful not to construe this critique as “anti-psychiatry.” There are amazing psychiatrists throughout the nation who understand and embrace the importance of a community and family-driven approach to mental health care. Unfortunately, the decision-making structures called for in this bill harken back to a much simpler time, when the psychiatric lens was all knowing and all seeing, operating from the perspective of “doing for” rather than “doing with.”

Powerful elements of the psychiatric community are vehement in their disgust with SAMHSA and their desire to right what they see as a wrong in terms of treatment approaches with the mentally ill. Consider this comment from Dr. Jeffrey Lieberman, M.D., Chairman, Department of Psychiatry, Columbia University College of Physicians and Surgeons, at the recent House committee hearing on H.R. 2646 (2:27 mark of the video):

  • "SAMHSA is a travesty from the psychiatry perspective - Efforts to innovate mental health care have been a disaster, from the academic psychiatric community perspective. SAMHSA is a proxy agency for the anti-psychiatry, for the anti-medical, anti-psychiatry approach to mental health care."

Are the feelings of Dr. Lieberman, presumably representing the entire psychiatric community in America, clear enough for you? Should those feelings shape the direction of mental health reform? When talking to your representatives, you need to be prepared to answer this question. Where are the voices of psychiatrists working at the local level who see the critical importance of a continuum of services and supports that go beyond medication management and supervised care? Both ends of the continuum must be in lock-step with each other.

National Mental Health Policy Laboratory (NMHPL)
The Assistant Secretary would handle leading and supervising the National Mental Health Policy Laboratory (NMHPL), which in turn, would be responsible for making decisions about grants approved for implementation. Sounds reasonable, right? But look closer at some of the most troubling guidelines for how decisions would be made (and by whom):

Pre-grant award review (Page  163, Line 13)
The bill requires that all grants and contracts be reviewed by the Energy and Commerce Subcommittee on Health 60 days prior to award. This additional requirement is most perplexing and appears to continue the overreach of congressional authority, blurring the lines between the responsibilities of Congress and those of the Executive Branch, through the HHS Secretary.

Review of Peer-review group (Page 165, Line 10)
Further chilling is the requirement that the House committee review all lists of members of peer-review groups responsible for reviewing awards.

Emphasis on advisory members who have no relevant experience with the grants being reviewed (Page 164, Line 8)
Another confounding requirement is that no grant advisory review members can have been a recipient of any grant, or participated in any program, about which the members are to advise. In other words, this bill suggests that peer review committees be created to include individuals with no context for the work being done. Surely, there is a better way to ensure objectivity than by amphibians rating the quality of proposals submitted by mammals.

One fifth of NMHPL staff appointed by Congress (Page 36, Line 15)
This bill proposes that 20 percent of NMHPL staff are congressional appointments. Having the power to dictate the views of one-fifth of the staff would be great for the political party in power. But what happens when that power balance in Congress changes? The havoc created by this one recommendation alone should cause politicians on both sides of the aisle to pause and think carefully about such an Orwellian approach to management.

Cultural inclusive language missing throughout
The tone and the focus of the bill would change dramatically if the authors were to incorporate a more culturally relevant understanding of what committee structures should look like and how evidence-based practices should be defined. The bill frequently refers to the necessity of making decisions about grant funding based on evidence-based practice. Unfortunately, the composition of the groups identified to make grant funding decisions reflected in the bill do not appear to take into account the need to be culturally inclusive. This is a fundamental flaw in the design of the bill and has far-reaching impact. If not addressed, efforts that emanate from any federal grants coming forth as a result of this bill will fail, as they will perpetuate the disconnect between policy made in isolation and practice that actually takes place in communities across America.

In summary
As stated at the beginning of this Morning Zen post, it doesn’t matter where you land on any of the key issues in the bill. Proposals for the use of AOT, the role of consumer advocacy groups, HIPAA, or where SAMHSA places its priorities all are doomed to failure. The structural integrity needed to facilitate the implementation of strategies in any of these areas of focus, as written in the bill, is inherently flawed, and thus, will result in a damaged bill destined to increased federal bureaucracy, wasteful spending, and a dangerous precedent of congressional supervision over executive branch activities.

Next steps - Let’s get busy!
Okay, now that you have a sense of the termite damage that has infested the foundation of this bill, let’s get to fixin’ it. Look for our upcoming posts on AOT, HIPAA and the importance of addressing cultural inclusion and the rampant disparities inherent in the current mental health delivery system. That ought to give you enough to chew on for the next couple of weeks. Be sure to share these posts with your representatives and advocacy partners as they come available. It is going to be a busy summer for mental health reform.

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network

Social-Emotional Learning is having an impact in urban schools!

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Morning Zen Guest Blog Post ~ Kevin Dwyer

clevelandCleveland Metropolitan School District was highlighted in Education Week (Evie Blad, June 10, 2015) for its system-wide, yes, system-wide, social-emotional learning (SEL) instruction combined with other best-practice interventions that address school climate and positive conditions for learning. The Ed Week article, Urban Districts Embrace Social-Emotional Learning is a must read for school leaders and education stakeholders to best understand that system-wide SEL and multiple interventions can address real world needs of students to be academically successful. 

Evie Blade’s Ed Week article also focused on the evaluation of these SEL interventions by the American Institutes for Research (AIR) in 8 urban school districts from Anchorage Alaska to Nashville, Tennessee.

I have talked about Cleveland’s innovative multi-interventions in previous Morning Zen posts on specific topics like alternatives to suspension, including last week’s on improving attendance. I noted their efforts in developing alternatives to suspension in establishing “planning centers” also noted in the Education Week article as well as regular school student support team problem solving for addressing what we sometimes call “early warning signs of academic and behavioral problems.”

Blade noted that these multi-year systemic SEL initiatives are taught as a curriculum in primary grades and also “…infuse social emotional concepts into the teaching of traditional subjects like history.”

Cleveland’s efforts are continuously evaluated for fidelity to the researched best-practice guidelines so that each school can look at its implementation grade and compare that to its student outcomes. What was reported by AIR in its presentation at the American Education Research Association conference in April titled: Results from an evaluation of a demonstration program to build systemic social emotional learning in eight urban districts, (Kimberly Kendziora, PhD, et.al.) was that student outcomes were positive when implementation had high fidelity. Cleveland showed higher math and reading scores, higher GPA and fewer suspensions. Cleveland also informally reported higher attendance in elementary schools (personal communication with Lori Hobson of CMSD). Nashville, showed higher math scores, attendance and fewer suspensions, although lower in Algebra 1. Students SEL competencies were highest in grade 3 and lowest in secondary grades. This may be related to the stage of implementation since most systems started with primary grade SEL curriculum. Surveys of school staffs and system administration showed positive associations with student social and emotional competence and some student achievement, attendance, and disciplinary outcomes. AIR concluded that “Implementation matters.”  

Communicating the effectiveness of SEL instruction encourages other systems to implement real SEL initiatives. Evaluating implementation fidelity continuously as we do academic instruction ensures we are doing our best for our students. Connecting SEL to early and intensive mental health interventions creates the synergy and assurance that our students get the support they need to succeed. 

My hat is off to Education Weeks reporter Evie Blade for her comprehensive article!

  • You can read Evie Blade's article here.

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dwyerKevin P. Dwyer, M.A., a Nationally Certified School Psychologist, is an education and child mental health consultant.  He recently served as a principal research associate for the American Institutes for Research. For over 30 years he practiced school psychology in public schools and held several local, state and national leadership positions in the fields of mental health and education, being responsible for the design, development, implementation and evaluation of programs and practices, for improving school climate, safety, and wellbeing for the education, and mental health of children.  He has helped school staff in many districts use data to inform decisions on improving caring and connectedness with students and professional peers.  His work, publications, presentations, and practices have influenced public policy and the development of efficient, family-focused collaborative child service systems.  During his 30 years as a public school psychologist, he worked directly with over 10,000 children and their families as well as trained over 6000 educators. He provided psychological services to children, including those with disabilities and those whose anxiety and mental health problems blocked learning and adjustment.  He assisted teachers and staff in supporting a caring, inclusive school climate for all children.  In 2007, the Maryland Coalition of Families awarded Mr. Dwyer and his wife for their work in making schools more family friendly.  He served as president of the National Association of School Psychologist and was given its highest honor, the Life-time Achievement Award.  In 2000, he received the Tipper Gore “Advocacy award for improving the lives and mental health of America’s children” from the National Mental Health Association.

VA report on decrease in suicide a "smoke screen" deflecting from the real truth

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Morning Zen Guest Blog Post ~ COL (Ret) George Patrin, M.D., CMHNetwork Advisory Council Member

The VA just released a report stating that suicides are down among Vets who are accessing their care vs. Vets who aren't. Here is an excerpt from the press release:

  • In the past eight years, VHA has enhanced mental health services across its system and supplemented it with specific programs for suicide prevention – like the Veterans Crisis Line. However, until recently information on suicide among all Veterans was not available. Earlier this month, a study on the changes in suicide rates for Veterans and non-Veterans was published that included indications that VHA patients were experiencing positive outcomes from care.

    “Going into this study, we thought we would see a higher rate of suicide among VHA users,” Dr. Robert M. Bossarte said. “This is because sickness is a risk factor for suicide, and the basic assumption was that those seeking care would be at a higher risk than those who weren’t. The data showed the opposite was true: VHA users had a lower suicide rate than non-VHA users.”

Sounds great, right? Before you celebrate this finding, let's look a little bit closer and talk about what this really means.

Is it a surprise to anyone that “VHA users had a lower suicide rate than non-VHA users?” The VA starts up a program(s) or service not offered before this (and why not?), and some Vets who had no options before go to the VA. Great. Those who still don’t trust the VA stay with what they had…and the suicide rate is higher without care than those getting any level of care at the VA.

This is nothing to boast about. The comparison needs to be VA care vs. other quality network care, whether DoD or civilian.

This report is distracting us from the reality of the lack of quality programs and processes, beginning with access to care problems in the National News, but more importantly the lack of true preventive services and poor continuity and integration of behavioral health, emergency care, and the primary care provider.To give the VA credit, our entire nation is stuck with a crisis-oriented sick-care system, especially for mental health issues. The whole system needs to be turned on its ear. The VA started this brand of holistic healthcare delivery years ago with the invention of Primary Care Teamlets, but seems to have lost that direction. (I know this because I’m enrolled to one, and it’s not what it’s advertised to be.)

What is more maddening is why the VA and entire DoD aren’t looking to repeat successes of other organizations, like the Henry Ford Health System in Detroit, who have figured out how to achieve zero suicides among those they are responsible for serving. While “one size doesn’t fit all,” the model works. To be sure, the VA does provide wonderful care in places, not due to their regulations, but due to exceptional employees who go the extra mile day in and day out. Thanks to those people for what they do.

But let’s not throw up smoke screens with reports like this to make ourselves feel better, deflecting us from the real truth. We are better than this…and our Vets and their Families deserve a better level of care!"

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george patrinCOL (Ret) George Patrin, M.D., spent over 23 years as an Army Pediatrician and Healthcare Administrator concentrating on Family Advocacy and Healthcare Process Improvement. His final assignment was as Northern Regional Command Special Projects Officer for Patient-Family Centered Healthcare assisting in writing DoD Patient Centered Medical Home (PCMH) Guidelines and Training. He has been a staunch advocate for both soldier and family member readiness throughout is military career. He is a sought after speaker on parenting education, child abuse prevention, school learning and behavior problems, and healthcare administration optimization. Dr. Patrin is a member of the Children's Mental Health Network Advisory Council. He can be contacted at patrin.george@gmail.com.

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