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SAMHSA Responds to Children's Trauma

By Melissa Capers

(Photo by Bob Denniston, courtesy of the Center for Multicultural Human Services)

When America was attacked on September 11, 2001, among those responding were the leaders and staff of 18 organizations newly chosen to be the first grantees of SAMHSA's National Child Traumatic Stress Initiative. Catalyzed by the urgent need created by the events of September 11, and enabled by SAMHSA funding to collaborate, cooperate, and respond, these organizations came together immediately and effectively-transforming the effort from Federal initiative to national service organization in record time.

"The National Child Traumatic Stress Initiative was developed to help us learn about and maximize trauma recovery among children, and the attacks of September 11 were a vivid reminder of just how essential these programs are," said Robert E. DeMartino, M.D., Associate Director of the Program in Trauma and Terrorism within SAMHSA's Center for Mental Health Services. "Through the grant application and review process, SAMHSA had access to the very best people who could respond to the trauma caused by these attacks. Our job was to call on them and support them in giving their best to the communities affected."

(Photo by Bob Denniston, courtesy of the Center for Multicultural Human Services)

Funding availability for the National Child Traumatic Stress (NCTS) Initiative was first announced in May 2001, and grants were awarded in September of that year. The Initiative aims to improve the standard of care and access to services for traumatized children and their families. It is designed to foster collaboration by establishing a national network of centers that cooperatively identify and develop effective treatments and services for children affected by trauma; collect clinical data on child trauma cases and services; develop resources on trauma for professionals, consumers of mental health services, and the public; develop trauma-focused public education, professional training, and field-development activities; and in so doing, improve treatment and services for all children and adolescents in the United States who have experienced traumatic events.

The architecture of the NCTS Network created by the Initiative is embedded in a three-tiered grant structure:

One grant established a National Center for Child Traumatic Stress, co-directed by Robert S. Pynoos, M.D., M.P.H., of the University of California–Los Angeles, and John Fairbank, Ph.D., of Duke University.
Five grants supported Intervention Development and Evaluation Centers to identify, support, improve, or develop effective treatment and service approaches for different child populations and different types of trauma. Most of these centers are affiliated with universities or other academic sites.
Twelve grants supported Community Treatment and Service Centers to provide and evaluate treatment and services in community settings.

An infusion of supplemental funding later allowed the NCTS Network to double in size, to a total of 10 Intervention Development and Evaluation grantees, and 26 Community Treatment and Service Centers.

According to Dr. Pynoos, the funding structure "provided a unique opportunity to integrate the scientific rigor of the academic centers with the wisdom of community-based service providers."

Grants were made for 3-year periods, beginning October 1, 2001. Grantees were asked to build into their proposal a 6-month planning period, and to address specifically the ways in which they intended to collaborate and support the NCTS Network and the National Center for Child Traumatic Stress.

September 11 Catalyst

The 6-month planning periods that grantees had scheduled were dramatically cut short by the events of September 11, 2001. Not yet officially announced when the terrorist attacks took place, the NCTS Network nevertheless provided a resource of expertise and experience that quickly mobilized to action.

"Ten minutes after we got notice of our award, we were asked to establish and lead a Traumatic Bereavement Task Force," recalls Judith A. Cohen, M.D., Project Director of the Allegheny General Hospital Center for Child Abuse and Traumatic Loss, an Intervention Development and Evaluation grantee.

This Task Force, comprised of New York City NCTS Network sites and other Initiative sites with related expertise, quickly developed four main goals:

To gather and distribute psycho-educational materials on traumatic bereavement in children to mental health professionals, teachers, and parents
To obtain standardized assessment instruments for childhood traumatic grief
To compile and assess what treatment materials on traumatic bereavement were available
To develop a manual for the treatment of preschool children suffering from traumatic bereavement.

Dr. Cohen reports that the Task Force members provided and quickly accessed a "diverse wealth of information regarding the exposure of children to traumatic grief." She and her colleagues at Allegheny General Hospital had already developed treatment manuals for individual and group treatment of children age 5 to 15. National Center Co-Director Pynoos had likewise participated in the development of a group treatment manual for adolescents.

The Traumatic Bereavement Task Force members reviewed the two treatment manuals and provided critical feedback and suggestions to assure cultural sensitivity and to incorporate the special aspects of the September 11 attacks. The manuals were then revised and distributed to more than 200 child trauma treatment professionals in New York City; Washington, DC; Pennsylvania; and other areas.

At the request of the Task Force, guidelines for treating traumatic grief in preschool children were developed by another Initiative grantee, the Early Trauma Treatment Network at the University of California at San Francisco, under the leadership of Alicia Leiberman, Ph.D. These guidelines were reviewed in fall 2002 with the aim of distributing them to professionals this summer.

Task Force member organizations also used SAMHSA support to leverage funding from the New York Office of Mental Health Services, the New York Times Fund, and the Silver Shield Foundation. Through combining these funding sources, Traumatic Bereavement Task Force members were able to conduct and videotape "train the trainer" workshops for professionals who treat New York City children, and to begin randomized treatment trials of Dr. Cohen's manual. Robin Goodman, Ph.D., and Elissa Brown, Ph.D., of the New York University Child Study Center (another Intervention Development and Evaluation Center) are conducting the randomized trials of the manual in collaboration with Dr. Cohen and her colleague, Anthony Mannarino, Ph.D., in Pittsburgh.

"It is incredible," says Dr. Cohen. "In less than a year, a manual was developed, revised, and distributed. More than 100 kids have been evaluated thus far, and a controlled research study is underway." According to Dr. Cohen, "This is the first known randomized and controlled trial specifically evaluating the impact of alternative treatments on childhood traumatic grief."

September 11 brought "unanticipated pressure to bear" on the NCTS Network, reports Dr. Cohen, with results that might be compared to the results of fission, or the way that pressure transforms a seam of coal into a diamond. In the same way, the urgency of September 11 formed an immediate culture of collaboration and cooperation. Grantees based in New York City began to work together in an accelerated way, and the Traumatic Bereavement Task Force brought together professionals from grantee organizations across the country in a way that would not have happened in the absence of such an emergency.

(Photo by Bob Denniston, courtesy of the Center for Multicultural Human Services)

The Network

The NCTS Network functions through a web-like structure of task forces and committees, through which various grantee organizations communicate and collaborate on projects of special interest, particular needs of the Network, and/or particular issues in child traumatic stress.

In addition to the Traumatic Bereavement Task Force, the Network supports a Forensic Medical Examination Working Group to establish ways to begin immediate therapeutic interventions for children receiving forensic medical examinations for sexual abuse, and a Complex Trauma Task Force to explore approaches to the assessment and treatment of children and adolescents with complex trauma histories.

Several committees focus on cross-cutting issues including data operations, measures, and training. The Child Sexual Abuse Task Force and Early Childhood Training Task Force each seek to enhance trauma treatment for children in these defined target populations.

These task forces and committees necessarily overlap. Grantees in the Forensic Medical Examination Working Group, for example, clearly have a special interest in the work of the Child Sexual Abuse Task Force, and may even serve both groups. Similarly, grantees working on developing a training curriculum for childcare providers will likely access the expertise of network members addressing various traumas in order to develop the best blend of age appropriate, trauma-specific information. These multiple and varied linkages keep the NCTS Network cohesive, and prevent development of exclusive pockets of interest or expertise.

The relatively recent emergence of the field of child traumatic stress helps to invigorate the NCTS Network. "The treatment of child traumatic stress is a fairly young field," explains Dr. Pynoos. "It was not until the late 1970s that professionals even began talking directly to children affected by trauma." From that point on, professionals recognized the need to communicate with one another, share knowledge, gain a greater understanding of how trauma affects children, and establish effective treatments designed specifically for traumatized children and adolescents.

Reflecting on the influence of the September 11 attacks, Dr. Pynoos observes, "In the same way that wars have brought attention to the effects of combat trauma, the events of September 11 have brought to the forefront the horrific impact of trauma on children, as well as on adults."

As the healing from September 11 is woven more completely into the fabric of the Nation's life, the task of the National Center and the NCTS Network will be to continue their original mission of education, training, and service, and to assure that the national learning that resulted from this tragedy is not lost as time passes.

For more information about the work of the National Center for Child Traumatic Stress and the National Child Traumatic Stress Network, visit www.mentalhealth.samhsa.gov/child/childhealth.asp, click on "The National Child Traumatic Stress Network."