Introduction

Thanks, I appreciate having the opportunity to talk with you all today.

At ACF, we focus on improving the well-being of the most vulnerable children and families in the United States. We have responsibility for a wide range of programs and initiatives, including but not limited to Head Start, child care, child welfare, child support, TANF, trafficking, refugee assistance, domestic violence, marriage and fatherhood, runaway and homeless youth, the unaccompanied children program, and more.

In our work, we rely heavily on SAMHSA’s resources and expertise, and we partner with SAMHSA in a number of key areas. We know many of you have strong partnerships with the human services agencies in your state. In the next few minutes, I want to talk about why these partnerships are so important, and highlight some ways in which attention to behavioral health is integral to the work of human services programs. I also want to highlight the importance of connecting children and families with the human services programs that can help families get stable income, stable housing, high quality early childhood education, supports for work, and other services that can be integral to child development and to helping parents live healthy and productive lives.

I’d like to start by telling you a couple of striking things I heard last week. Last Tuesday, I was in Delaware, at a session celebrating the state’s accomplishments in strengthening its early childhood education efforts and the important role played by a Race to the Top Early Learning Challenge grant. The state has taken multiple steps in increasing provider participation in a tiered rating system, raising the number of programs that are rated as high quality, and more. At a roundtable, several participants emphasized that early childhood mental health consultants that were now available to programs. They talked about the challenges when young children are distressed or engaging in challenging behavior and the crucial role that consultants were playing in helping programs work with children and parents. And, they talked about the dramatic reductions in suspensions and expulsions when programs could draw on these consultants.

That was Tuesday. Then, on Thursday and Friday, I spent a couple of days in Utah, learning about the state’s efforts to strengthen overall effectiveness of its TANF program and to seek to address intergenerational poverty by intensively working with TANF families in which the parent received assistance as a child. There are a number of aspects of the state’s efforts --- an emphasis on coaching, motivational interviewing, taking a whole-family approach, strengthening staff understanding of trauma and stress, greater use of home visiting. And, in efforts to address intergenerational poverty, every office either has on site or has access to a mental health clinician who can work with participants, staff, or both, as needed. And, staff emphasized that the insights from the behavioral health experts were providing key help for highly stressed families, and often, highly stressed staff.

These are just last week’s examples. But, they reflect how integrating behavioral health services can make a difference in obvious and less obvious ways for human services programs.

ACF Work on Behavioral Health, Trauma, and Toxic Stress
 

As you know, many individuals with behavioral health challenges turn to human services programs, and trauma, stress, and poverty can put people at elevated risk for behavioral health challenges.

In addition, in recent years, both in ACF and in states, there’s been an increasing appreciation of the research on adverse childhood experiences, trauma, and toxic stress and the potential implications of new findings in brain science relating to these.

We also looked closely at the research indicating that when children experience strong, frequent, or prolonged adversity without adequate adult support, the prolonged stress can disrupt the development of brain architecture and other organ systems, and have lifelong negative consequences. We think a strong implication of this work is that public policy needs to reduce the stressors that too often characterize the lives of poor children, families and communities, while strengthening the capacities of caregivers to cope with current stressors and the continuing effects of past ones.

We also recognize that depression is widespread among poor and low income mothers and that one in nine infants live with a mother experiencing severe depression.

And, so at ACF, we have increased our attention to behavioral health, trauma, efforts to prevent and address toxic stress, strategies for strengthening resilience, executive function and self-regulation, and parenting skills. We are supporting relevant research, engaging in internal education of our staff, and identifying opportunities across ACF programs.

As one component of this work, we’re participating in the Subcommittee on Trauma and Early Intervention, under the HHS Behavioral Health Coordinating Committee co-led by SAMHSA and the Assistant Secretary for Health. The Subcommittee is developing a toolkit on trauma-informed approaches in human services, which we’re planning to release this fall.

The toolkit will discuss key concepts related to trauma, stress, resilience, and executive function, with resource kits for evidence-based, evidence-informed, and innovative practice, and efforts to distill lessons learned and promising practices.

We recognize that there’s a core understanding that will benefit all human services programs, but there are also important differences in programmatic implications, based upon program goals, responsibilities, and populations being served.

Trauma in the Populations We Serve

There are programs in which virtually all or a very large share of participants are likely to be currently experiencing or have previously experienced trauma. This will include children, and often parents, in the child welfare system, survivors of domestic violence and trafficking, refugees and unaccompanied children. These programs need to be directly responsive, often with one on one case work.

There are also programs where individuals come in for a very specific service or benefit, the population is diverse, and the principal unifying characteristic is that they’re low income. An example is the LIHEAP Program, for which families are seeking energy assistance. In these programs, perhaps the most important relevance of being trauma-informed is ensuring that the program does not re-traumatize people through abrupt and insensitive program administration.

Between the two ends of the continuum are programs that serve a diverse group of children and families, ranging from those in short-term economic need to persons who may be facing multiple behavioral and other challenges, and for which being trauma-informed calls for both awareness of how trauma may affect day-to-day interactions, how to most constructively engage with a diverse population, and how to identify when there is a need for referral to more comprehensive services.

I want to highlight a few examples of how this understanding is being reflected in our work, both in addressing behavioral health broadly and with specific attention to trauma.

Behavioral Health and Child Welfare

First, in child welfare, data suggests that about one in six children in foster care have a mental health diagnosis. These children are, on average, twice as likely to have experienced three or more placement changes and to spend nearly two and one half times as long in foster care as other children.

For states, this poses challenges both in providing needed services and treatment and in recruiting and retaining resource parents for therapeutic foster care placements.

To address these challenges, states are enhancing service provider contracts and foster care standards, implementing promising trauma and wrap-around models, comprehensive assessment protocols, and child placement procedures aimed at ensuring children’s mental health needs are identified and met.

In addition, the Children’s Bureau has funded 20 demonstration projects to integrate trauma-informed practices into child welfare. These demonstration projects are partnering with mental health service providers and implementing trauma screening, assessments, and on-going progress monitoring.

The National Center for Evidenced Based Practice in Child Welfare is working to build the capacity of the public child welfare and mental health frontline workforces and leadership to partner in implementing trauma-informed, evidence-based practices.

And, SAMHSA’s National Child Trauma Stress Network has developed the Child Welfare Trauma Training Toolkit, an evidence-informed curriculum for Child Welfare staff.

Behavioral Health and Refugees

Turning to the refugee program --- Many refugees experienced torture, violence, or other severe circumstances prior to coming to the US. Our Office of Refugee Resettlement has funded a three year technical assistance project that focuses on building capacity among organizations serving survivors of torture and severe trauma to provide integrated behavioral health care in partnership with community health centers.

The TA providers developed the Survivors of Torture Integrated Care Continuum based on SAMHSA’s Standard Framework for Levels of Integrated Care. This tool will be used to design capacity building and training to help ORR grantees move toward integrated care.

ORR and SAMHSA initiated Mental Health First Aid Training for community members and direct service staff at refugee-serving organizations.

ORR is also tracking which states are providing mental health screening during the initial health screening which newly arrived refugees receive. Currently, we know of 27 states that perform mental health screening.

Behavioral Health and Domestic Violence

To strengthen the capacity of programs serving victims of domestic violence, our Family Violence Prevention and Services Program is the primary funder for the National Center on Domestic Violence, Trauma & Mental Health. This center offers resources, training, and technical assistance related to the intersection of trauma, domestic violence, mental health, and substance abuse and focuses on building the capacity of domestic violence programs to become trauma-informed organizations and offer trauma-focused services for domestic violence survivors and their children.

Supporting Children’s Social-Emotional Wellbeing and Behavioral Health

Supporting children’s social-emotional and behavioral health is central to ACF’s early childhood work.

Over the last decade, infant/early childhood mental health consultation has emerged as an important evidence-based strategy to promote young children’s positive social and emotional development and behavioral health and to prevent, identify, and reduce the impact of mental health problems among young children and their families.

Head Start has been at the forefront of these efforts, as the Head Start Program Performance Standards require that each program has a mental health consultant.

Among many other initiatives underway, we are partnering with SAMHSA and HRSA to fund the National Center of Excellence in Early Childhood Mental Health Consultation.

The Center will develop a state of the art toolkit on building and sustaining a strong early childhood mental health consultation system, and will provide TA to States and tribes, using the toolkit, to build new systems.

When I talked about Delaware, I noted the important role of consultations in preventing and reducing expulsions and suspensions from early learning settings.

In 2014, HHS and ED released the first ever federal policy statement on expulsion and suspension practices in early learning settings, providing recommendations to states and early learning programs to curb the rates of these counterproductive practices.

Since then, a number of States and local communities have begun taking action, and we encourage these efforts.

Our interest in trauma, adverse childhood experiences and toxic stress has spurred us to ask how early childhood programs can do more to support prevention and provide needed services.

One important element of this effort has involved establishing and supporting the Buffering Toxic Stress Consortium, in which six sites around the country are rigorously evaluating promising parenting interventions in Early Head Start settings intended to reduce the risks of children experiencing toxic stress.

We’re also funding a set of Head Start University Partnerships focusing on Dual-Generation Approaches.

These projects are implementing and evaluating promising approaches that combine intensive, high quality, child focused programs with intensive, high quality, adult focused services to support both parent well-being and children’s school readiness.

The grantees are targeting a range of adult outcomes, including perceived stress and stress physiology, self-regulation and depression.

Substance Abuse Disorders and Human Services Programs

I want to turn now to the importance of services relating to substance abuse disorders in human services programs.

In child welfare, we know that substance abuse seldom appears alone in the lives of children and families.

While many families with substance abuse challenges come to the attention of child welfare, jurisdictions must often address not only substance abuse but other co-occurring issues such as mental illness, domestic violence, and housing instability.

While there is great variation in jurisdictions, studies indicate that most substantiated child abuse and neglect cases include substance use by a custodial parent or guardian.

Parents in such circumstances are often unable to provide a stable, nurturing home environment, they have a lower likelihood of successful reunification with their children, and their children tend to stay longer in foster care.

Overall, the number of children in foster care is substantially lower than it was twenty years ago, but we’ve seen growth in the number of children in care since 2012, and a range of sources indicate that at least part of the growth is attributable to substance abuse and growth in the use of opioids.

While there are large variations in state reporting, the percentage of cases in which a parental drug problem is cited as associated with the child’s removal climbed from 28 to 32 percent between 2012 and 2015, with a higher share among parents of infants entering care.

And, we think that the number of children who enter care due to a parental substance use is significantly underreported.

Together, SAMHSA and ACF co-fund the National Center on Substance Abuse and Child Welfare which provides information, expert consultation, training and technical assistance to child welfare agencies, dependency courts, and substance abuse treatment professionals that focus on improving outcomes for children, parents, and families.

The Center’s current projects include recently published guidance on the Treatment of Pregnant Women with Opioid Use Disorders.

ACF also continues to fund Regional Partnership Grants, which promote adult recovery from substance use disorders and stabilize families through multi-system collaborations.

And, to maximize help for children with Fetal Alcohol Syndrome Disorder, ACF has partnered with the Centers for Disease Control to conduct an exploratory research project to obtain information about current screening practices in child welfare agencies and the kinds of services that are currently offered.

We also see the importance of addressing substance abuse in our trafficking work.

Last year, ACF established our Office on Trafficking in Persons to improve coordination and strengthen ACF’s attention to policy and practice issues relating to its anti-trafficking efforts.

While we don’t have definitive data on how many trafficking victim’s substance abuse affects, we know that drugs and addiction can put victims at risk of being trafficked, be used as a coping mechanism, and be forced upon victims to keep them trapped.

A number of studies have identified the serious and often complex mental health needs of victims of human trafficking, including significant levels of posttraumatic stress disorder, anxiety, depression and dissociative disorders.

In 2014, researchers surveyed survivors of sex trafficking in the U.S. and found that 88 percent of those surveyed encountered a health care professional in a clinical or service setting during their exploitation, but the provider did not recognize indicators of trafficking.

ACF’s Office on Trafficking in Persons and HHS’s Office on Women’s Health collaborated with survivors and experts to develop the Stop. Observe. Ask. Respond to Human Trafficking (SOAR) training for health care providers, public health professionals, social workers, and other behavioral health professionals.

This training is designed to equip these professionals with resources and tools to increase the identification of potential victims and appropriately assist in their work settings.

And finally, substance use issues have arisen in a number of states relating to the TANF program, and this is an area where your partnerships can be particularly important.

While the data here is not perfect, most estimates find that 5 to 10 percent of adults receiving assistance have substance abuse problems, rates that are a few percentage points higher than those in the general population.

This points to the need to ensure access to treatment for TANF families. However, sometimes in addition to or in lieu of treatment, fifteen state legislatures have mandated some form of drug testing for TANF applicants or recipients, and in some instances denying assistance either based on the results of the test or if the individual refuses to take it.

Some of these laws have raised constitutional issues, as courts have found that drug tests constitute searches, therefore suspicion less testing should not be allowed under the Fourth Amendment.

If your state is considering this type of legislation or if already has it in place, this presents an important opportunity for TANF and substance abuse agencies to work together to ensure that state policy is based on the best available knowledge and research, and to be sure that testing and identification is tied to treatment.

Conclusion

In these remarks, I’ve only touched on some of the key areas of partnerships --- there’s more to say about these, along with issues relating to unaccompanied children, families and young people experiencing homelessness, tribal issues, fatherhood programs, and more. I’m happy to talk about these and other related issues in the QA session. But, to conclude, we recognize that to help families succeed, human services programs must address mental health and substance abuse challenges, and that underscores the importance of partnerships with you. We welcome your thoughts and advice on what we can do to support and strengthen these partnerships, and we thank you for your work.