A View from the Helicopter

I'm not a clinician, I'm here as a project evaluator with the intention of getting sense of the what the field of mental health care for traumatized children is like these days -- at least for those community based agencies and academic experts who are fortunate enough to have support from SAMHSA as part of the National Child Traumatic Stress Network.

There's plenty of good news here -- then I'll give you the bad news.

Good news bulletin #1: I have heard scarcely a word about psych meds. The only way pills have come up is as a peripheral note that somebody who is part of a case scenario had been prescribed something. The NCTSN is not about drugging kids.

Bulletin #2: The DSM-IV is equally conspicuous by its absence. There is absolutely no interest in classifying kids' problems as diseases, tossing around disease categories, or using diagnostic labels to guide treatment.

Bulletin #3: The elaborate psychodynamic narratives that once dominated psychology are gone, at least from this group. The kinds of insights that are relevant to them are much more straightforward: the child feels guilty because he failed to protect his mother; the shadows falling across the bed remind the girl of her father entering the room with the light from the hallway behind him; the mother is encouraging the child's sleeplessness because she craves the child's company at night to ease her own loneliness.

The approaches to child trauma are pragmatic, focused on equipping children with knowledge, skills and strategies for overcoming their grief, fear, and pain and living successfully in the world in which they happen to be. There is a great deal of attention to cultural context, to children's experience and wishes, and to addressing practical needs for safety and effective nurturing.

Now the bad news: How many children who carry the scars of traumatic experience get this kind of attention? What percentage of kids who are disruptive in school just get slapped with a label of ADHD and given a vial of speed? What percentage of children who become aggressive, or addicted, or socially isolated, get any understanding and meaningful help from competent adults at all, and just end up in the juvenile justice system or go on to failed lives?

The fact is that the funding available from health insurance, public or private, just does not pay for these kinds of in-depth counseling and social work interventions. Even the most seriously disturbed children, who are involved in state child protection systems, are very lucky to get adequate help. The NCTSI right now is funding 33 programs in the entire United States, some of which do not even provide direct services. No doubt there is some other contract or grant funding from states or philanthropies here and there, but we all know what happens to the vast majority of children who suffer abuse or neglect, witness violence, experience catastrophes. And I just want to remind everyone that back when the putative president was still compassionately conservative, this was his signature issue. He was going to see to it that every child who needed help got it.

The president's budget for the new fiscal year phases out the NCTSI entirely. Its annual cost -- about 2 hours of war in Iraq.