SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

NATIONAL ADVISORY COUNCIL

38th Meeting

Wednesday,

December 7, 2005

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Acting Chairperson and Executive Director]{.underline}

Daryl W. Kade, M.A.

Executive Director, SAMHSA National Advisory Council

Associate Administrator for Policy, Planning,

and Budget, SAMHSA

1 Choke Cherry Road, Room 8-1083

Rockville, MD 20857

[Executive Secretary]{.underline}

Toian Vaughn, M.S.W.

Executive Secretary, SAMHSA National Advisory Council

1 Choke Cherry Road, Room 8-1089

Rockville, MD 20857

[Members]{.underline}

Gwynneth A. E. Dieter

Mental Health Advocate

U.S. Embassy Belize

Unit 7401

Faye Annette Gary, Ed.D., R.N.

Professor, Case Western Reserve University

Frances Payne Bolton School of Nursing

1099 Euclid Avenue

Cleveland, OH 44106-4904

Barbara Huff

Consultant

The Federation of Families for Children\'s Mental Health

2837 North Plumthicket Circle

Wichita, KS 67226

Thomas A. Kirk, Jr., Ph.D.

Commissioner

Department of Mental Health and Addiction Services

410 Capitol Avenue, 4th Floor

P.O. Box 341231, MS #14 Com

Hartford, CT 06134

IN ATTENDANCE:

Thomas Lewis

President and CEO

The Fishing School

7017 16th Street, N.W.

Washington, D.C. 20012

Theresa Racicot

Former First Lady of Montana

901 15th Street South #201

Arlington, VA 22202

Kenneth D. Stark

Director

Division of Alcohol and Substance Abuse

Department of Social and Health Services

P.O. Box 45330

Olympia, WA 98504-5330

Kathleen Sullivan

Journalist

Four Mission Court

Rancho Mirage, CA 92270

[C O N T E N T S]{.underline}

PAGE

Opening Remarks

Daryl W. Kade, M.A.

Acting Chairperson and Executive Director,

SAMHSA National Advisory Council and

Associate Administrator, Office of Policy

Planning, and Budget, SAMHSA 6

Medicare Modernization Act

Anita Everett, SAMHSA 6

Discussion 12

Preventing Underage Drinking

SAMHSA\'s Underage Drinking Prevention Effort

Stephen Wing

Associate Administrator for Alcohol

Office of Policy, Planning, and Budget, SAMHSA 39

Underage Drinking Prevention Advertising Campaign

Alvera Stern, Ed.D., SAMHSA 44

Discussion 49

National Child Traumatic Stress Initiative

Campaign (NCTSI)

Overview of the NCTSI

Sybil K. Goldman, M.S.W.

Senior Advisor on Children

Office of the Administrator, SAMHSA 63

Kennedy Krieger Institute Family Center,

Baltimore, Maryland

Elizabeth Thompson, Ph.D.

Director, Division of Clinical Services 69

[C O N T E N T S]{.underline}

PAGE

National Child Traumatic Stress Initiative

Campaign (NCTSI)

DePelchin Children\'s Center,

Houston, Texas

Robert Hartman, M.S.W.

Executive Vice President and COO 88

Discussion 100

Public Comment 109

Closing Remarks

Daryl W. Kade, M.A. 117

[P R O C E E D I N G S]{.underline} (9:00 a.m.)

MS. KADE: Good morning, everyone. We\'re about to begin. Anita Everett
is going to talk with us about the Medicare Modernization Act.

MS. EVERETT: Thank you. Medicare recipients, because of their age,
because they\'re past 65, about 14 percent of them are disabled. They
are on Medicare because they\'re disabled. So by far and away, the
majority of the population, the beneficiaries that are eligible for this
benefit, are geriatric individuals.

Of those 42 million, about 7 million are what we call dually eligible
individuals, or they are people that have both Medicaid and Medicare.
That\'s a particular concern to us at SAMHSA, because maybe those
individuals are dually eligible in association with a mental illness
and/or substance abuse, but primarily mental illness. So that\'s a high
impact population.

The other thing that\'s particularly important about that group of
people, or the duals as they\'re called, is that because of the way the
law is set up, the interaction of federal laws, those individuals no
longer can receive their medications through Medicaid, so they switch
over to Medicare as of January 1st, 2006.

So whereas individuals who have been used to getting their medicines
through Medicaid with all the systems and the access that goes on with
that, this will also cover the Medicare benefit. So that is a group that
we have been following and working with CMS quite closely on.

The other group that\'s particularly likely to benefit from this is the
low income individuals. There are actually three tiers of beneficiaries
by financial assets. There is the Medicare individuals which will meet
their state requirements for Medicaid eligibility, and then there is the
in between group that are called low income groups. We right now are
actively trying to get people to make sure they sign up for this
benefit.

Those are individuals that are 150 percent of the federal poverty level
and less, and those individuals, there are no premiums, very limited
co-pays, and their deductible is very limited. It depends a little bit
on their assets. So that\'s a population that\'s going to benefit
tremendously from this benefit.

Other than that, the other sorts of things in particular in the whole
benefit that SAMHSA has been working very closely with CMS on is the
special provisions that are made for people with mental illness with
regards to this. Because of concern that certain populations would be
highly impacted by the benefit itself, and remember the whole benefit is
sort of couched on the idea of encouraging competition between the
companies and making arrangements with individual prescription drug
plans. So competition is the cornerstone of this whole thing.

There are certain special categories that were created by CMS with our
encouragement that provide extra access to certain sets of medications.
There are six categories of special interest, three of which concern
medications which individuals with mental illness often need. Those
would be antidepressants, antipsychotics, and anticonvulsants, which are
often used for the treatment of bipolar disorder and mood disorders.

The other three are immunosuppressants. In other words, a common use for
that would be transplant individuals, chemotherapy agents, and HIV/AIDS
drugs. So those are the six categories.

What is special about those categories of medicines is that rather than
the norm, which is that two medicines in each category have to be
covered by each of these drug plans, all of the medicines in those
categories have to be covered by each of the plans everywhere.

As the plans which have come out which they have in mid October, we
found that there is pretty good adherence to that. In other words, CMS
has provided oversight to them, and they follow through with that. So
there are about six, for instance, of what we call atypical
antipsychotic agents. All of those are available on all of the
prescription drug plans for individuals to access.

So that\'s the broad benefit. Certainly I can answer any questions if
anybody has any. We\'ve been working very closely with CMS on that. What
I thought I would do is just run down some of the things that SAMHSA
particularly has been doing. That is what is highlighted for you on this
single page handout. Has that been distributed? You have that.

These are some of the activities that SAMHSA has done. This is a high
priority of course for the administration, and also for Mr. Curie. So
these are some of the activities, just sort of a listing of things that
we have been engaged with SAMHSA on behalf of things that CMS is
primarily responsible for administering.

We focus mostly on education and outreach in the areas of mental health
and substance abuse, so that portions of this entire benefit are more
likely to impact individuals with mental health and substance abuse
issues.

Administrator Curie, as well as other agency leads, have been
incorporating specific information about the prescription drug benefit,
sort of their regular numerous national public appearances that they
make throughout their time here, primarily encouraging people to sign up
for the benefit and representing the basic information on what the
benefit represents.

We have created an email list to the states through their state mental
health directors and substance abuse directors to send that to the
person within that state who is the lead on this particular benefit.
Sometimes it is in the Mental Health office, sometimes it is in other
offices within state government, the way states are organized. So we
have an email list of all the state leads on this project.

When you send them information, we try to sort of cull information and
send in information that\'s directly relevant to the populations that
have mental illness and substance abuse.

We created a page on our SAMHSA website which is sort of a nexus of
links to other pages. We have created an education of outreach
partnerships with several mental health advocacy groups throughout
interagency funding between us and CMS. The groups that were the
recipients of this education and outreach oriented grant include the
National Council of Community Behavioral Health, or NCCBH, NASMHPD, the
National Association of State Mental Health Program Directors, the
National Mental Health Association, and the National Alliance for the
Mentally Ill.

We have participated in regular meetings. The substance abuse advocacy
community as a whole is not as centrally oriented towards this benefit,
primarily because the medications are used in a different way from the
treatment of substance abuse disorders. They are much more sort of
ancillary to the treatment, rather than the center of the treatment.

However, we have engaged in several substance abuse groups so that they
are aware of this and provide information to their membership on what
this benefit is all about, and what opportunities it could represent for
individuals that they are working with.

We have created opportunities for CMS staff to come and present mental
health and substance abuse and provider group meetings for large groups,
national meetings that CMS otherwise would probably have had less
ability to access. We have dedicated an entire edition of the SAMHSA
News to that, and that also should be a handout here. That is dedicated
to the Medicare benefit.

We have promoted the prescription drug benefit through distribution of
CMS brochures at SAMHSA booth exhibits. The other handout you have with
this packet here is information that came directly from CMS. Actually,
when I was given the opportunity to do this, a CMS staff person from
downtown hand delivered this to me to provide to you, so hopefully
you\'ll have a chance to look through that a little bit.

This is a benefit that\'s sent out, it\'s a resource kit that is sent
out for what CMS is calling Partners, for people who are in positions to
help other recipients or beneficiaries sign up for the benefit directly.

We are providing training for SAMHSA staff. We have 520 employees, and
we think it\'s important for our employees to know how to access this
benefit on behalf of their parents, other family members, or other
neighbors that may be enrolled to influence positively. That is actually
happening next week to myself and the CMS staff coming here for the
presentation regarding that.

Other more minor things like participating in education experiences,
there is a grand rounds online series that we participated in to provide
technical information to professionals on that.

That\'s pretty much the summary of what SAMHSA has been doing. I
intended to give you a little bit of a snapshot of the broad benefit.
I\'m happy to answer questions if anyone has any particular questions
about either SAMHSA\'s role in this or the benefit itself.

MS. SULLIVAN: We could be here all day.

MS. EVERETT: Right.

MR. KIRK: The dual eligibles are of particular concern to us in
Connecticut. Can you tell what the spirit is among CMS as to ‑‑ my
understanding is that the plans, for example, the one was with 17
vendors and then there were 44 different variations of the plans, and
that formulary can change on a fairly regular basis.

We\'ll get our people set to the medications that they\'re on. On
average, they\'re on five. Two months later, the formulary can change,
and we\'re going through the same thing again. We\'re concerned about
people being moved to medications, generics, after they\'ve been on
medications for a long period of time, and decompensating as a result
and going back into the hospital. We\'re simply trying to keep track of
these kinds of changes.

What\'s the spirit of this? Does CMS understand this?

MS. EVERETT: My primary contact over at CMS is a Dr. Jeffrey Kellman,
who is the chief medical officer of all of CMS and is in Mark
McClellan\'s office. So that\'s the level that we\'ve been interacting
with.

I can tell you honestly through numerous interactions with them, they
have been very receptive to our issues that relate to mental illness and
special needs. That is part of the reason that we were successful in
helping them identify those three methods in particular, groups of
medicines, all of which should be available for our individuals.

So the antipsychotics, the antidepressants, and the anticonvulsant
medications should be available on all of the formularies. So you\'re
right, that is a concern, but there are several things that are set up
to safeguard people having to change with regards to that.

I\'m not sure if I answered your question. People who have mental
illness for those medicines should not have to change to a generic.
There is no particular provision set up if the person is also on cardiac
medicine to have to change to a different lipid agent, for instance, or
things like that.

We were able to secure this really special provision for those
medications, because of the sensitive nature of people who have been
stable on particular medicines, not having to change and go through
that.

There are also several appeals processes that are available to the
consumer and their family members. A family member can be involved in
this on behalf of an individual who is designated as an authorized
representative, which is also important here, and/or the treating
physician can appeal. If another medication that a person might need is
not on the formulary, other than those three classes of medicine, say a
side effect medicine or different things like that, they can appeal to
have it put on the formulary.

You can also appeal the tier of medicine category. These medicines, a
strategy of the prescription drug plans in keeping cost down, is to have
the medicine on a different co-pay tier. It is a very complicated
benefit, and that\'s probably the hardest thing about the whole thing.

So the duals, otherwise, payment wise, there are three ways you pay for
this benefit. The duals will not have to pay a premium, and they will
not have to pay a deductible, but they do have a co-pay per prescription
that can be between \$1 and \$3.

MR. KIRK: Is it a fact that the co-pay cannot be, this is federally
mandated, cannot be waived? Again, going back to our situation, we have
people on average on five medications. Sometimes those prescriptions are
for relatively short periods of time, so during the course of a month
they might have to be renewed three times because of the severity of the
condition.

So that co-pay for these folks may seem like a small piece of change,
but it\'s not a small piece of change.

MS. EVERETT: We\'re very aware of that. A \$3 co-pay, for instance, if
the medicine is put on a higher tier, can be a problem, particularly if
you multiply that by five, and you know the realities of living on
disability income. That\'s a very tricky issue also, because the
kickback laws involve that.

If there is not the capacity in the federal regulation to waive the
co-pay that has to be charged, where that can be waived is at the point
of sale at the pharmacy. The pharmacy can decide not to bill for the
co-pay. There also can be a system set up where clinics, you know, a
person can have a charitable group help them with the co-pay, but it
can\'t be officially waived by the federal government. Neither can a
drugstore have an official policy of waiving the co-pay, because that
gets into encouraging people to come to a particular drug store and use
particular medicines that could be associated with a kickback.

We have really tried to work that out. A number of the pharmacy
companies have been interested in setting up opportunities to help
offset the co-pay, doing that in a way that is not directly connected
with one particular company that might have undue influence on the
selection of one or the other of the antipsychotics.

It has been quite a challenge. So that is actively being worked on, but
for right now, the co-pay can\'t be waived. Now, a state can also choose
to work with the co-pay through their Medicaid program, but that\'s very
variable.

MR. KIRK: Yes. In Connecticut, the legislature passed a bill and they
have \$5 million available for the co-pays. This goes beyond mental
health. This is MR, across the board.

Our concern is whether legislators want to do what to do what
Connecticut did. In other words, people understand that this is going to
be an at-will cost that\'s going to continue to along. My concern is
that somewhere along the line legislators will say, well, we just can\'t
afford this anymore. We either go into the state\'s pharmacies, or we go
ahead and try to supply medications in a different way.

Let me ask one other question, though, and I\'ll leave you alone. My
understanding is that January 1 is the go-live date to put in the plans.
I know in Connecticut, Congressman Larson is arguing and supposedly
there are other congresspersons of the same orientation that this is
just too complicated and the period for getting into this should be
extended two years.

Is there any spirit in your understanding to phasing in implementation
of this in a slower way than what is being planned?

MS. EVERETT: There is absolutely no spirit to changing anything that I
have heard at all. To be honest, it came up in the wake of Katrina,
because that so preoccupied a lot of the energy and efforts of folks at
CMS and us in working on sort of responding to that.

Federal questions were raised at that time about delaying the onset.
There is no thought at all that they want to delay in any way the onset.
The January 1st deadline is a pretty drop dead deadline.

So what happens on January 1st, I think you had asked that question. As
of November 15th, so a month ago, individuals can enroll in the program,
but no benefits start until January 1st. The big thing for us that
happens on January 1st is that that\'s the date beyond which Medicaid
cannot be used to acquire medicines.

MS. SULLIVAN: Medicaid?

MS. EVERETT: Medicaid. If you\'re dual eligible and you have been
previously receiving your medicines through Medicaid, you can no longer
do that by federal law, because Medicaid always has to be a payer of
last resort.

Yes, you can sign up in advance so that everything is all ready to go.
November 15th, that\'s correct.

MS. SULLIVAN: Yes. I\'m sorry.

MS. EVERETT: Any other questions?

DR. GARY: I wanted to ask a question that is a concern of mine. I hope
it\'s not a real issue, but I have to ask it anyway.

I guess about two months ago, the data were shared, and a report was
generated by the National Institute of Mental Health about the efficacy
of the atypical antipsychotics when compared to the second generation
psychotics. One of the findings was that from a therapeutic perspective,
there was little difference.

Now, I\'m not discussing some of the issues with the study design, but I
am wondering with that particular finding if that would influence policy
to the degree that some patients who have done very well on the
atypicals, such as olanzipine and risperidone, geodone, et cetera, would
be put in the position where the state or federal government would elect
to have those drugs on formulary and clinics and hospitals, and not be
atypicals? How do you see that impacting the populations across the
United States? Do you have any anticipatory kind of policy in place to
deal with that? Or is it a problem?

I\'m thinking that if olanzipine cost \$17 a pill, and you can get
Haldol and some of the other drugs for \$2 or \$3, then that is a
tremendous cost savings to the enterprise. With this data from NIMH,
I\'m just wondering how it\'s going to influence the policy of some
people who really, really watch these data and use it to their
advantage.

Now, the problem is people respond to drugs on an individual basis. Some
do well on one drug, and others do well on the other. But the data,
we\'re talking about evidence-based practice. If the data says that
there is not much difference and you can save billions of dollars, then
where does that leave us with patient care?

MS. EVERETT: That\'s an excellent question. I do think that particular
study, it\'s called the CATIE study, opens up the door a little bit
towards reconsidering the older antipsychotics as legitimate treatment,
feasible legitimate treatment. as opposed to only contemporary
medications which do have far fewer side effects, and are much better
tolerated by most people might be acceptable to use.

That came up almost immediately after the CATIE study was released. The
CATIE study was a complicated study, and we won\'t cover that right now,
although I\'d be happy to do that at some point if anyone is interested,
our perspective on it.

But what was published was only the first phase of the CATIE study,
which was interesting for us to keep in mind. So it is very preliminary
data. But the way it came out was that the older medicines are just
about as good as the newer medicines, at least by patients making
decisions to stay on the medications.

It came up where several of the prescription drugs plans called CMS and
wanted to change that so that it didn\'t have to cover all of the more
contemporary medicines. Because remember, we had the antipsychotic
medicines that are in that special category that all of them had to be
covered for all Medicare recipients or beneficiaries.

So there was sort of an idea that maybe we don\'t need to have that
special requirement that CMS created for those medicines. CMS was very
steadfast in defending that no, we\'re not changing that policy at all,
we\'re keeping it so that individuals have access to all of the new
generation or newer antipsychotic medications.

So for now, that has been a very firm opinion of theirs. Over time, that
particular provision was not actually written in the act, the federal
acts that enabled Medicare. So over time, you\'re right, that could
unravel. I can tell you honestly right now that that is not the intent
at all in the Central Office at CMS. But it may be that we need to
maintain some vigilance on that in the advocacy communities to assure
that that benefit is preserved for individuals over time.

We know we\'re good for the first several years of the program the way
it is set up. So that\'s important. I can also tell you that a number of
the groups that we work with on a daily basis are very aggressively
tracking who is using what medication in these categories of medicines
that go along with mental health treatments, the antipsychotics,
antidepressants, and the mood stabilizers.

So making sure that people have access to those is a prime concern of a
lot of the groups that we\'re working closely with. So you\'re right,
that\'s not a guaranteed long-term for the benefit, but for the
immediate outroll, the benefit is preserved that individuals will be
able to stay on that without hard core, first fail types of procedures.

There is not a first fail allowed say, for instance, to use your
example, first fail Haldol or one of the other medicines, to get to
olanzipine. Drug companies cannot do that at this point in time,
absolutely not. If it happens, that needs to be reported to CMS
immediately, or myself, if any one of you is in a position where you see
anything like that, because that\'s not supposed to happen.

DR. GARY: I just wonder if it would be wise to have some kind of fairly
aggressive position about it. Just let me tell you why.

Because at one time, I spent most of my life in the State of Florida. At
one time, there was specific kinds of guidelines about treatment. People
could be cleansed on the antipsychotics in some facilities, not all, but
in some. I was on the Governor\'s advocacy group, and we effectively
lobbied to have that removed, because we thought it was cruel and
unnecessary for a person to have to have X numbers of psychotic episodes
before they could get to the third generation medications.

So I didn\'t want us in the name of improving mental health and well
being to take any backwards steps. That\'s something that I\'m very
concerned about and ask that we put some mechanism in place so that we
can track what might be happening, the potential of what can happen to
individuals.

MS. EVERETT: That\'s a very good thought about that. I can think that
through and sort of provide a little bit more specific information on
what is being done with regards to tracking that.

DR. GARY: That would be good.

MS. SULLIVAN: You know, Anita, I really like to consider myself somewhat
of a person who can get my arm around things, and intelligent. But I go
to a county health clinic, and there is no way that these people are
going to be able to put their hands around prescription Plan D.

If there was just a one-page flyer, just a little folder or brochure
that said just like the medical bill of rights that they have, just like
the medical bill of rights that said this is what you\'re entitled to,
this is the co-pay, and maybe it was done by the state with SAMHSA, of
saying this is what you need with prescription Plan D, that it\'s not
what the doctor says, and not what the nurse says ‑‑ because I tell you,
the doctor is going to say ask the nurse, and the nurse is going to say
ask the doctor and ask the front desk. No one is going to want to
explain this.

I know in my residence there is someone who is actually going to be
giving a lecture to the elderly. The city is providing lectures.

I see Carol Burnett on the air, and I don\'t know if she is being, you
know, paid for by an insurance company. I am so confused. If I\'m
confused, right, I know everyone in my clinic is confused.

There is no way. I mean, I see all of this. You have to go to a website.
Well, I know everyone in my clinic doesn\'t have a computer. I see this
as all going inside the system. But if a brochure can be in the clinic,
do you know what I mean? Where it\'s sitting right up there when you go
to check in so that people who are disabled know on a date.

I mean, how do we get this just straight out into the hands? Instead of
sending it to the providers and sending it to people, I mean, just right
in the hands. The window is so small. I mean, do we have one brochure
that tells you, this is what you\'re entitled to?

In the State of Connecticut, maybe Tom can help me with this. Your
co-pays are going to be different, every state is going to be different.
Ken, your co-pay is going to be different. Do you know what I mean?
Every state is going to be different. This is going to be a NASMHPD
issue, right? A NASMHPD issue?

MS. EVERETT: Yes, that\'s right.

MS. SULLIVAN: So every state and federal is going to have to come up
with their co-pay issues. I mean, this is something that everyone has to
get their arm around to explain before all these people who are mentally
ill and have substance abuse are going to be denied their benefits on
disability.

What\'s the window of opportunity to sign up for D? Nine months?

MR. KIRK: No. A plan is assigned to you if you\'re dual eligible as of
November 1, right? You are automatically enrolled in the plan. And then
if you choose, the consumer can choose someplace after that to move
to ‑‑

MS. SULLIVAN: To D?

MS. EVERETT: The duals can always change. They\'re a special enrollment
category. Once a month is the way it is operationalized.

MS. SULLIVAN: Yes, I know, but if you are disabled, you have to sign up
for D.

MS. EVERETT: Yes.

MS. SULLIVAN: Right.

MS. EVERETT: You have to sign up for it, unless you\'re dually eligible.
They are automatically enrolled.

MS. SULLIVAN: Okay. But if you\'re mentally ill, you have to sign up for
D?

MS. EVERETT: Unless you had Medicaid before.

MS. SULLIVAN: Right.

MS. EVERETT: In which case you\'ll be automatically signed up. You can
change, but you\'ll be automatically signed up.

MS. SULLIVAN: This is just like way beyond me. I mean, and these people
that are walking in there just have no clue. You know, even people who
you see on these ads, can there be one brochure for every state?

Can Steve Mayberg put one out? Ken, whoever is replacing you? I want to
hear your reaction. I\'d love to hear, Tom, your reaction, before I see
people in a year and a half and they realize it\'s gone, you know?

MS. EVERETT: I mean, there are a couple of things that I can tell you
that we\'ve done to help with that a little bit, realizing that this is
an extremely complex benefit, to do what we can to also make sure that
the case manager or someone in that function for someone who could help
traverse this. They may have a case load of 50 to 60 or maybe 100 or so
individuals, some of whom would be eligible for this, that that
individual can kind of help sort out and understand the benefit.

MS. SULLIVAN: But the nurses don\'t understand it, and I know some of
the shrinks don\'t understand it. You know what I mean? I mean, I know
when I ask them, they don\'t. That\'s why the cities are now holding
these conferences, but you have to be mobile, you have to have bus fare
to get to these things. You have to have babysitters to get to these
things. We\'re talking about indigents and the very poor who don\'t even
know that the cities are holding these conferences.

It is this Catch-22, and the bottom that need this information most, or
sometimes the illiterate need it.

MS. EVERETT: Right.

MS. SULLIVAN: I mean, this is something that is going to hurt the very,
very poor. How do we help these people before they fall through the
cracks? And that\'s the point of this prescription drug plan.

MS. EVERETT: Right, right. I mean, one of the things that actually will,
at this point in the benefit, the duals, people who have both Medicaid
and Medicare, the most poor individuals, have been automatically signed
up.

One of the things that is a simple place to start is to look at the
program that that individual has been signed up for and see what is
available.

MS. SULLIVAN: One of the things is to look at it. Who is to look at?
This is extremely frustrating. Should someone get to the table and say,
we need to extend, like Tom said, this window. Maybe it\'s Charlie, and
maybe other people at HHS have to say, we have to extend this window to
really see this window of opportunity, extend this window before people
fall through the cracks.

I mean, we need to really look at this and say oh, we\'ve drawn this
line too short. I know we have a very small window to talk about this
today, but this is so important, that maybe we should hold this over for
more discussion about this on the table in April or May, because this is
just so important with so many people falling through the cracks. If you
put this on your national calendar, I\'m sure this is.

MR. KIRK: Just real quick. Different states are trying to educate the
consumers in different ways. One of the things that we found is that we
do these mass kinds of things, websites and all those kinds of things.
The persons that we\'re most concerned about are dual eligibles.

So you\'ve got to get to the case manager that sees this person three,
four, five days a week. That\'s the one that\'s sitting there, and they
need to understand the plan. NASMHPD has been very aggressive in
tracking this. For those that are interested, Bob Glover, who is the
Executive Director, in one of the briefing pieces shows the things that
they\'re doing.

I think the message, at least from my point of view, is this just has to
be something that we track. It has to be tracked probably more so
post-1/1 when the key is turned, that you can discuss different ways to
educate. There are lots of different ways that are being used around the
country. But when all is said and done, Joe Smith is going to go on some
sort of plan on January 1st, and he\'s going to be on five plans, and
some of them are going to work, and some are not going to work. That\'s
what I\'m concerned about. That\'s what needs to be tracked.

MS. EVERETT: Certainly that\'s true, but we can set up something for
follow-up on this. I wanted to hear from this side of the table quickly,
and I am getting signals that our time is running out.

MS. VAUGHN: Ken Stark?

MR. STARK: I agree with everything everybody said. It is confusing, and
states are doing a number of different things, the Medicaid offices, the
mental health offices, the alcohol and drug offices.

I agree with what Tom just said in terms of the tracking, but the
tracking has got to be twofold. The issue of eligibility and access are
always two different things. I have seen many, many times where in both
private sector and public sector, we have contracted with entities, we
have put all this stuff in there that folks are eligible for, but that
doesn\'t necessarily mean they get access.

So if we\'re going to track, we need to track not only the transition as
to all the enrollees and did that part go smooth, but we need to track
the issue that Tom Kirk brought up about are folks going to be able to
get access to those medications, or are we going to run into scenarios
where the plans using their medical directors or their other gatekeepers
going to transition people off of certain medications to others under
the guise of studies that show cost effectiveness, cost efficiencies.

So I\'m hopeful that SAMHSA working with CMS is going to look at a
tracking system, both relative to the enrollee side, as well as relative
to the access side and transitions that are caused by the plans once
folks get on them.

MS. EVERETT: I appreciate that comment. We are very actively involved in
that, but I think also some way to create feedback from each of you who
are in positions to see how this plays out more locally would be very
helpful for me and SAMHSA in the process of doing this. So some
follow-up on this I think is a good idea.

MS. KADE: What we\'ll do is we\'ll continue the dialogue for about five
minutes. I just checked with Andy and Toian. What we\'ll do is we\'ll
relay the dialogue back to Mr. Curie and talk about a follow-up
conference call or an April agenda item. But we\'ll make him aware of
the issues.

MS. VAUGHN: Gwynneth or Barbara, did you have a comment?

MS. DIETER: I mean, I\'m not particularly knowledgeable, but from the
consumer viewpoint, the idea that each case worker is going to have the
information that you have seems impossible to me.

I mean, you\'re doing a great job. I feel a lot of sympathy for you,
because you understand that it has been given to you, but to deliver the
information about how it works to the people that need it seems to be
impossible.

The only thing would be, from my viewpoint, would be what Kathleen
suggested, which would be in each county or state or whatever to try to
actually define on a short, two pieces of paper, as best you can what
needs to be done, and send that out to everyone. Then obviously give
them numbers so that they can call you.

They are going to end up spending more money tracking what isn\'t being
done than the money we\'re saving to begin with. I don\'t know. It is
very difficult. It\'s great that you have understood all this and can do
it, but I just don\'t see it working.

MS. EVERETT: I think by April, if that\'s the time frame, we\'ll have a
lot more information. It depends on how much time we want to take. It
sounds like there is a lot of interest here. We could certainly have
some of our friends from CMS come over and do a more formal
presentation. By April, we should know a little bit about information
for dually eligible individuals that are automatically enrolled.

The worst thing that can happen to them is they could be signed up to a
program that has less favorable co-pays. But basically they are
protected, and should be able to access their medicine. That being of
the most concern.

If they are assigned to a plan that they don\'t want to be in, they can
change every month. So we can worry about them, but only so much
immediately in January. The people that stand to benefit the most from
this are people that probably don\'t have much access to meds right now,
these middle income people, lowish income. There are about 8 million of
them.

CMS is all over tracking them and doing whatever we can to make sure
that those people sign up, because they are not automatically signed up.
They had to actively do that. Information has been mailed to them and
things like that, but this is a very transient population.

MS. DIETER: Yes. I hear what you\'re saying.

MS. EVERETT: Right. That could fit for those 8 million if they are not
also falling into the Medicaid category. They are not automatically
signed up. I\'m maybe getting into too much detail.

MS. HUFF: I just wanted to mention that I\'m the former director at the
Federation of Families for Children\'s Mental Health. I noticed on your
list of people that you informed and did workshops with and that sort of
thing, they weren\'t on there. There are a lot of grandparents raising
grandchildren, grandparents having mental health problems, and parents
raising children who have mental health problems, and just because it\'s
a children\'s organization, children\'s mental health organization, I
wouldn\'t not educate them in the same way you\'ve educated NAMI and
some of the other organizations to understand.

MS. EVERETT: Sure.

MS. HUFF: And I also understand for the carrier of the message, and
we\'re kind of beating you up a little bit about this, and I don\'t want
you to feel that way, even though if I were standing in your shoes, I
would be feeling that way.

I am willing to turn it over to Faye at this moment, but I just wanted
you to consider allowing those other organizations the same opportunity.

MS. EVERETT: That might be a good idea. A lot of that, the Area Agencies
on Aging have a lot to do with dissemination. Eighty-five percent of the
Medicare recipient population that are aging, you know, are Medicare
recipients because they\'re aging, so that\'s one avenue.

Folks from that organization, they don\'t know that. I think it\'s very
worth me trying to contact them and set up something with their
leadership to see if they have any questions, or how we can help them
with that. I think that\'s a great idea.

MS. HUFF: I\'d be happy to make that (inaudible).

MS. EVERETT: That would be great.

MS. HUFF: Also there are some other (inaudible).

MS. EVERETT: Great.

MS. KADE: I think we\'ll have one more speaker. Faye?

DR. GARY: I\'ll make this very quick. I wanted to get back to the model
that Tom and Ken had begun to lay out. One talked about eligibility and
the other talked about access.

I wanted to add to that model treatment to also say that when we begin
to look at this, that we somehow track the quality of treatment. Perhaps
one of the advantages of the atypicals is fewer side effects, fewer
movement disorders like tardive dyskinesia, et cetera.

I think we should begin now to think about policy that states that when
patients come in for renewal of medications, there will be a systematic
assessment of the movement disorders and other side effects that might
be associated with the change of their drug regimens from the second
generation to the atypicals, which is the third generation drug.

MS. EVERETT: Thank you very much for that comment. That reminds me of
one of our sort of highest priorities, which is providing consumer
choice. I think that\'s correct, yes.

MS. KADE: So what we\'ll do is we\'re going to review the minutes of the
meeting and identify a list of issues that have been identified.

What I will do is talk to Mr. Curie and see whether or not we could
arrange a conference call before our next meeting. Our next meeting is
actually scheduled in June. So before June if we could get some
representatives from CMS on a conference call with the members to go
over the issues that have been raised, we will try and do that, and we
will get back to you.

MS. EVERETT: Thank you very much.

MS. KADE: Thank you, Anita.

We\'re running a little late, but our next agenda item is on underage
drinking. I have the remarks that Charlie was going to read to you. I\'m
going to read them to you because I think it\'s important to get some
context, and then quickly move onto our speakers.

Charlie wanted to move directly to this item this morning, which we
intercepted with this dialogue on Medicare. Steve Wing, the Associate
Administrator for Alcohol Prevention, and rather than Mark Weber, we
have his representative to make a brief presentation as well.

Yesterday Mr. Curie talked briefly about the need for SAMHSA to do more
as an agency to help prevent underage drinking. He also mentioned that
we were not doing enough together as a nation, and that it\'s very
challenging.

Secretary Leavitt called the Interagency Coordinating Committee on the
Prevention of Underage Drinking to convene a national meeting. As chair
of the meeting, Mr. Curie has assured this committee that each member of
the committee is deeply committed to turning words to action. Each is
committed to working closely with each other across departments and
agencies to get the job done.

In fact, the Surgeon General, Dr. Richard Carmona, who is a member of
the committee, announced his intention to launch a first-ever Call to
Action on the prevention of underage drinking during the second day of
the meeting.

The committee also includes representatives from the Departments of
Health and Human Services, Education, Justice, Transportation, the
Office of National Drug Control Policy, Department of Defense, the
Department of Treasury, and ex officio representation from the Federal
Trade Commission.

On October 31st, Secretary Leavitt opened the meeting, which had an
unprecedented roster of leaders and top level state delegations and
attendees from across the country. The Secretary called on each governor
to assemble a team of experts in their respected state. Each governor
responded, and teams were sent from every state and several territories
of the District of Columbia, with the exception of the state teams from
the Gulf Coast region, which we are organizing a follow-up meeting for.

The meeting was about finding the common ground to save lives. In short,
the meeting was about turning words into action. Our nation has acted on
preventing drug use. The result is that teen use is down. We have acted
on preventing tobacco use by young people, and the result is teen
tobacco use is down. Yes, underage drinking remains a serious,
persistent, and stubborn problem.

Alcohol is the most widely used substance of abuse among America\'s
youth. A higher percentage of youth age 12 to 20 use alcohol than use
tobacco or illicit drugs. Underage drinking is a leading public health
problem in this country. We are about to establish federal goals for
reducing underage drinking. Building accountability, we have set
measurable targets for reducing the prevalence of underage alcohol use,
reducing binge alcohol use, and increasing the age of first use.

We can and must meet these targets. It is time to get real focused and
push back. For too long, underage drinking has been accepted as a rite
of passage in this country. Far too many young people, their friends and
families have paid the price.

Let\'s change attitudes towards teen drinking from acceptance to
abstinence, and recognize the importance of parents talking to their
children early and often about alcohol, especially before they start
drinking. We must replace an environment that all too often enables
underage alcohol use with an environment that discourages it.

It is clear that our greatest chance of success depends on our ability
to achieve a comprehensive, national approach to preventing and reducing
underage drinking.

Steve Wing will now share a few details of SAMHSA\'s and the Interagency
Coordinating Committee\'s role in moving that process ahead.

Steve?

MR. WING: Thanks. We have a list of SAMHSA\'s underage drinking
activities on their way. We had a little glitch, so you\'ll get them in
a few minutes, and I\'ll speak from my notes until you do.

There are eight main activities, some of which Daryl has already
mentioned that we\'re involved in. The first, as Daryl mentioned, is the
Interagency Coordinating Committee that Mr. Curie chairs. That\'s been
in place for a year and a half and will be a standing committee. It
serves to try to coordinate federal activities.

The second is the SPF SIGs, which you heard about yesterday. Third is
Reach Out Now and the teach-ins. Fourth is the national meeting, the
town hall meetings. Sixth, the website. Seventh, report to Congress, and
finally the Ad Council.

I\'m not going to say a lot about any of these because of the time
constraints, but I\'m going to defer completely on the Ad Council
campaign to my colleague, Alvera Stern. There\'s no point in my covering
it as well.

I have already talked a little bit about the Interagency Coordinating
Committee. As I said, that\'s a standing committee. Yesterday you heard
about the Strategic Prevention Framework State Incentive Grants, the SPF
SIGs. They have an emphasis on underage drinking. I don\'t really have a
lot to add, except to make the point that they are expected to make a
significant impact on underage drinking by making it far more likely
that the prevention systems address this important issue.

There has been a heavy emphasis on preventing illicit drug use. I think
that folks have often forgotten that alcohol is the substance of choice
for America\'s youth, that a higher percentage of youth age 12 to 20 use
alcohol than use tobacco or illicit drugs, making underage drinking the
leading public health problem.

The Reach Out Now campaign and the teach-ins are something that we have
been doing for a number of years now. That\'s a SAMHSA project in
collaboration with Scholastic magazine. We do underage drinking
prevention materials for fifth and sixth graders and their parents.
Those materials are sent to every classroom in the United States,
public, private, and parochial. Each classroom gets 30 copies of the
parent\'s section, so kids can bring them home from class and talk to
their parents about them.

One of the little twists to that is something we call the teach-ins.
They were started by Hope Taft, who has been very involved in the
prevention of underage alcohol use for years. Ms. Taft suggested when
this program began that it might be good to draw attention to it by
having someone prominent in the community teach the materials in a fifth
grade classroom with the hope of getting press coverage and draw
attention to the issue.

She was somehow able to convince the governor of Ohio to do that, and he
did. That started teach-ins across the country. We do that every year,
and we will be doing it again this year. It is one of the SAMHSA
signature programs. If you want more information, there\'s a website. It
is teachin.samhsa.gov. Teachin is all one word. That gives you
information both on the teach-ins, and on the Reach Out Now materials.

Daryl has already talked about the national meeting that was convened at
the end of October and early November. Three hundred twenty four team
members attended. They were from all states in the country, with the
exception of people from the Gulf States that couldn\'t come because of
Katrina. There were an additional 88 observers representing public
health groups, advocacy groups, and the alcohol beverage industry.

That meeting included a speech by the Secretary, Mr. Curie was the host,
panelists, very distinguished researchers in the field, state panels
talking about what states have done, and concluded with the Surgeon
General announcing that he was going to do a Call to Action on underage
drinking.

That meeting, we have gotten very positive feedback on. When you hold
those meetings, you want to have something that people can go home and
do next. Because if you don\'t, they just kind of float off, and
everybody has an interesting time.

So as a follow-up to that, we asked each state team to join with us in
promoting town hall meetings on underage drinking across the United
States in March of 2006. I\'m not going to take the time to go through
all the details on the town hall meetings. I have given you a little
two-page write-up, a Q and A form, that goes over what we\'re looking
for.

This is a joint activity between SAMHSA and the Interagency Coordinating
Committee on the Prevention of Underage Drinking. So all of the agencies
involved will be helping with this. SAMHSA, however, is stepping up to
the plate by providing \$1,000 to each of the 1,500 communities across
the country. It\'s not enough to open a whole coalition, but it is
enough to help a coalition with some of the costs to hold a town hall
meeting. This two-page Q and A will give you some of the details about
what we\'re expecting and hoping to achieve.

Those meetings, the communities that are going to receive the stipends
in each state will be selected by the state teams that attended the
meeting earlier this fall. So we\'re asking the teams to kind of get
together and find communities that they think would do a good job. The
overall goal here is to try to get some national momentum behind looking
at this issue. One of our problems, which you\'ll hear more about from
Alvera, is that most parents do not see this as a serious problem.

One of the reasons is that they don\'t understand a lot of the research
that has come out in the last ten years that show that there are not
only the short-term consequences of underage drinking which we all know
about, the risk of injury, death from drunk driving and that sort of
thing, but there are also some long-term consequences, such as the
increased likelihood of having an alcohol problem later in life.

Another thing that we\'ve done through the Interagency Committee with
SAMHSA\'s support is a website called stopalcoholabuse.gov. That\'s an
all government site where people can get access to information about
underage drinking from all the federal agencies.

You might want to, if this is an issue you\'re interested in, you might
want to take a look at that website. We had some of the materials from
the underage drinking in place several weeks ago, including a link to
NIAAA. They have a new publication out that summarizes their research on
all the areas related to underage drinking, the epidemiology, as well as
the consequences.

There is a report to Congress, the first annual report on underage
drinking that SAMHSA and ICCPUD developed. I can\'t tell you much more
about it. It is there, and that contains the goals that Daryl mentioned.

That leads me to the Ad Council campaign. I\'m going to turn it over to
Alvera Stern at this point. You\'ll find this very interesting.

DR. STERN: Hello, everybody. I\'m going to go over very, very briefly
the background to the Ad Council Underage Drinking Prevention Program,
and then talk very briefly about some of the research, show you the
PSAs, and then talk briefly about the next steps.

We did a fairly extensive review of the research, and in fact got about
250 germane articles, two volumes that any of you who are interested may
look at, and much of the research was from SAMHSA, NIAAA, the AMA, and
our friends across the nation.

We found out, first of all, that about 29 percent of underage people, 12
to 20, reported current, that is monthly, alcohol use. Of those, about
40 percent were 12 to 17. We also know from the research that the number
of deaths for underage kids caused by alcohol is 6.5 times more than the
deaths from all other illegal drugs combined.

We found also that kids who begin drinking alcohol before the age of 15
are five times more likely to develop alcohol problems than those who
start after the age of 21. That was an \'03 study from NSDUH. Joe
Gfroerer in OAS tells me that that percentage, that five times, is
probably a little higher in the newer data.

Many kids in this country start lifetime use around 11 or 12. Between 12
and 15, that percentage of kids using goes up fairly dramatically, a
mathematical progression. We also know that of people in treatment,
alcohol-dependent adults, about 95 percent say that they started
drinking, they had their first drink before the age of 21.

In our research of parents of which we just pulled out, of course you
know there is an enormous amount of research here. Most kids say it\'s
easy to obtain alcohol, and it is very easy to get it from their homes.

In studies by NIAAA and others, we have known for some time that the
protective factors from parents are very, very significant. Kids are
much less likely to drink if their parents are bonded with them, if
their parents have conversations with them, if their parents have
neither very, very, very rigid rules, nor very, very, very loose rules,
but have a rubber band approach to parenting where the kids know the
boundaries, and the boundaries change as the kids get older.

We found out that parents do know that they have influence. They don\'t
know how much influence they have, and very often they underestimate the
influence. They have difficulties knowing quite what to say to their
kids about the subject.

From this early research, we made the objective to encourage parents to
speak with their children early and often, with two goals in mind. To
delay the onset of underage drinking, and to ultimately reduce underage
drinking.

After this literature research, we went to the parents and the kids
themselves, and we did focus groups in various areas of the country with
various different types of parents and their children. What we found is
that most parents felt there were other issues that were much more
critical than underage drinking.

Drug use, much more critical, sexual activity, much more critical in
their eyes. Parents generally thought it was other kids drinking, not
their kids. There was a lot of denial in all the focus groups. Their
kids simply weren\'t part of the large percentages we quoted to them.
They simply did not believe that drinking could possibly start in middle
school.

We also had a very interesting happening at the same time. We were
working with the ad agency Kaplan Thaler. A bunch of 30-somethings,
early 40-somethings that didn\'t believe the research either, because
they all had kids in this age group. There were many conversations that
happened after our meetings with the ad agency personnel as they went
home and talked to their kids and said, I just don\'t believe this.

The parents were concerned about safety issues, if they were concerned
about underage drinking. They talked a lot about the dangers of drunk
driving. But they said, you know, we did it, it\'s not a big deal as
long as the kids drink at home or drink in moderation, it\'s fine.

After this research, oh, one more thing. We went over the statistics,
some that I showed you, and others, to see what parents resonated with.
There was really only one statistic that made them sit up and take
notice. That is the statistic that if kids start drinking before the age
of 15, they are five times more likely to be alcohol-dependent after 21.

From this focus group, we chose our target audience, parents with kids
age 11 to 15, targeting parents of kids in early middle school. Kids who
have started not yet drinking. The key message we wanted to get through
to parents was the chances of the young person developing an alcohol
problem increases the earlier the child starts drinking. With the
go-home message, the action message, of start talking with your kids
before they start drinking.

(PSA shown.)

DR. STERN: There are some radio ads, two printouts, and you\'ll see them
on either side of the podium there.

We have packaged these, and they are on your table. We can mail them to
you. If you open the package, inside are the print copies and a little
fact sheet. Now, we are going to make these available starting with
training for the town meetings. The first two trainings, one is in
Boston, one is in Reno, at the end of January. We\'ll be training
prevention people in the regions to organize town meetings, and also get
hold of the PSAs and go down to the local media and get them on the air,
radio, and print.

So we are printing community kits that will be a little flatter than
this, because they\'ll have CDs instead of the VHS tapes. Those will go
across the country. The media were mailed these kits last week, and
we\'re expecting to start them playing probably in a week, or two, or
three, and definitely in January.

We\'re also going to make sure that in the Scholastic handouts to all
teachers, fifth and six grade, this work is highlighted, and parents are
directed to the stopalcoholabuse.gov. On stopalcoholabuse.gov, you can
click on the PSA and then go to a website for families that talks about
alcohol abuse and its prevention.

So questions for Steve and I?

MS. RACICOT: I want to know, are you buying time? Or are they all PSAs?
Even when you send these out to the press, are we purchasing air time?

MR. WING: No, we\'re not buying time.

MS. RACICOT: So we don\'t have a lot of guarantees that they\'re going
to be willing to run them?

MR. WING: Well, we\'re hopeful.

DR. STERN: Let me just say something about that. These were from ONDCP
and they were accepted, which means that they will get much higher play
time because, as you know, ONDCP buys the time for drug ads, but when
the station buys time to use the drug ad, they have to promise to do a
match time for another set of ads, and there are only a very few set of
ads that qualify for the match.

MS. RACICOT: What has been the industry response? Do you know? Have you
gotten any from them?

DR. STERN: Yes. We heard from the Beer Industry Executive Council,
Coors, and of course our advocates. We worked with the industry. The
legislation that earmarked this money for the Ad Council said that we
must do this in consultation with the industry. So we have had two
meetings with the industry and advocates that were public and organized
ahead of time.

Then Steve has done quite a bit of talking with the industry. I have
done that in consultation with the Ad Council. These ads, they have been
well received by CSPI also.

MR. WING: It was sort of interesting, actually, this happened actually
that the advocacy groups and the industry groups jointly signed the
letter to Congress requesting that the Ad Council campaign be funded
this year. That was surprising.

The only other thing I\'d add is that this campaign tracks closely
recommendations from the Institute of Medicine\'s report on underage
drinking several years ago that recommended that we target parents, that
there wasn\'t enough evidence for targeting children.

DR. STERN: The other thing, I just got a note from someone suggesting
that I mention that these ads just won a very prestigious Silver Bill
Award. The Ad Council takes all of its campaigns every year and sends
them out to the ad agencies that do creative work, and those peers vote
on the best ad campaigns of the year.

The Ad Council this year had 80 campaigns, 8-0. The peers voted this the
best.

(Applause.)

MR. STARK: I was just going to make sort of a comment that it is nice to
see that alcohol is getting play time on the federal agenda now, more so
than it did awhile back, and it needs to, especially given all the
statistics that are pretty obvious.

But it is sad to hear that the alcohol and beverage industry still seems
to somehow have an impact on the federal budget not buying time for
these ads. That\'s an opinion, and I\'m free to give it. I\'ll continue
to state that. It\'s an historical problem. I think everybody who works
in the alcohol/drug field knows.

It would certainly be nice to see more dollars appropriated to actually
purchase time on the alcohol side of these ads, and not just the drug
side. Especially given the fact that it is the number one killer drug.

MS. DIETER: I agree. I mean, I would like to see this ad on ten times a
day everywhere. I actually didn\'t realize that the federal government
didn\'t pay for ads against the use of alcohol. That\'s shocking.

MS. HUFF: You kind of answered it and kind of didn\'t, but I was just
wondering why it was important that we had adopted the industry\'s
collaborative effort on this.

MR. WING: Well, we were directed to do it by Congress.

MS. HUFF: I got that.

MR. WING: It was a condition of the funding.

Kathleen?

MS. SULLIVAN: I emailed Tom. I think I emailed you and everyone on the
council about a New York Times piece where the alcohol companies were
actually targeting young drinkers in the guise of doing these kind of
promotions, you know, little parties, but it was aimed at binge
drinking.

I think, Tom, you emailed me back that you had some success at the state
level of nipping it in the bud. This gives us an opportunity to at least
talk about it.

MR. KIRK: I wish that was my response. I think the reality was that when
I spoke to my prevention people, they were aware of some of these kinds
of activities going on, but the article basically was that particularly
college settings, binge drinking was some sort of game where you throw
something and then you drink.

I think my comfort was that within some work that we are doing with all
of the community colleges and state colleges in Connecticut, this is one
of the focuses. We haven\'t seen yet what the outcome of that is.

MS. SULLIVAN: Even because it\'s becoming such a social, binge drinking
is becoming such a hit thing, with young kids even seeing it, I mean, I
just wanted to bring that up, as we talked about binge drinking before.
It\'s just so popular on campuses.

MR. WING: I think you\'re talking about the beer bong or something like
that.

MS. SULLIVAN: Yes.

MR. WING: My understanding is that lot of the support for that has been
withdrawn as a result of public pressure.

MS. SULLIVAN: Yes, yes, exactly.

MS. RACICOT: I want to say one thing about the advertising. The Internet
is a disaster. They have all kinds of kids video games buying beer at
websites that lure the kids in to play some little car racing game, and
then get into Bud Lite, Miller, and all the rest of them.

The advertising is unbelievable, and I think basically we as Americans
and parents are totally unaware of it. I don\'t know if any of you have
seen CAMY\'s presentation on alcohol advertising. It will make your hair
stand right on end.

Our kids are so exposed to alcohol in their lives from the time they\'re
this age on up. I frankly can\'t imagine anything else in this country
that we would be screaming from the rooftops about, lead in our paint,
lead in our water, we can\'t do anything now without a car seat that
costs \$250 in this country. And yet we expose our children every day to
the worst poison in their lives, and we do it because it\'s a legal
substance that makes money, and because of power lobby.

I\'m free to say this. Frankly, I think it\'s the truth, and until we
address this as a country and a culture, we\'re still going to have the
number one drug that our children get every day. I mean, I saw a young
girl, 22 years old, who is a meth addict who has been clean for four
years.

She stood in front of a group at a press conference, and she said, I
started at 14 with alcohol. At 15, I was smoking pot, at 16 I was raped.
At 17, I started meth, and for the next nine months, I spent every day
trying to do what I could do to get it. She said, my parents, God bless
them, mortgaged their house and practically sold their lives to put me
in treatment. She said, I\'m 22 years old today, I started college, and
there\'s not one day I don\'t wish I could use this drug. She started
with alcohol.

We are naive if we don\'t believe it\'s the gateway to what is
destroying people\'s lives. There is a lot of proof now that you can
have alcohol problems the rest of your life by 15 to 18 years old. This
is no longer a disease that you get by the time you\'re 40. You get this
young. It starts young, and it destroys your life.

The other thing I want to say, and then I\'m done. This is my soap box,
in case you haven\'t noticed. The other thing I want to say is if you
have a child that has a problem with alcohol, don\'t think you can\'t
talk about it. That is when you need to get up and talk about it.

Kids make choices that destroy their lives. It is not a shame on you as
a parent. Parents need help, they need empowerment. If your kid screws
up, tell other people and give them some courage to start looking at
their own kids. I say that as a parent who has walked this road. I know.

The Surgeon General\'s report was on the table four years ago. The
Surgeon General\'s Call to Action, and somehow it fell off. I am so
grateful that it\'s going to be done today. This nation still responds
to doctors speaking. When the Surgeon General, the nation\'s doctor,
says we need to look at childhood and underage drinking, it\'s going to
carry power. It did with tobacco. Thank God it\'s going to happen, and I
hope it\'s an incredible piece.

MR. WING: Thank you.

I think, Ms. Sullivan, you had something.

MS. SULLIVAN: When did the FCC change the rules allowing advertising,
liquor advertising, back on the air?

MR. WING: I don\'t think they have changed.

MS. SULLIVAN: Oh, you betcha.

MR. WING: Not in the last year, though.

MS. SULLIVAN: I mean, I see liquor ads constantly on television now. I
mean, at least on the cable networks which, as far as I\'m concerned,
are basically the same. I wonder if there is a study that shows the
pervasiveness, if that indeed is the reason for the increase of teen
drinking. If there is a parallel of teen drinking increase to the
frequency of advertising on television. If that is the parallel
increase, who should do that study?

MR. WING: There are studies right now. Ms. Racicot mentioned CAMY, which
has some very interesting stuff on their website. It is camy.org.

However, I must tell you that NIAAA, which is the custodian of science
on this, has concluded as recently as two months ago that the evidence
is inconclusive on that subject. That\'s the basis for which we and the
FCC and everybody has to proceed.

Also, the IOM report concluded that the science ‑‑ now this was several
years ago, but the science was sufficiently inconclusive. There was not
sufficient evidence to allow them to recommend that it override the
constitutional protections on free speech. The chair of that was a
constitutional scholar.

So that\'s my best understanding of what the experts and the scientists
are saying. Now, that may change over the next year, because there are a
number of studies that are out. That\'s where we are right now.

MS. DIETER: I just want to support what Theresa said. I just agree with
you 100 percent. It has been a passion for me since before this all
began for various reasons.

I want to say the ads that you created are wonderful, particularly
because they address two things that I think are so important. I think
that most parents still do not know that the young age of initiation of
drugs has these dire consequences. That\'s a piece of information, and
that\'s what you\'re giving them.

Number two, they don\'t know that there is anything they can do about
it. I was totally surprised with the first drug use report, or whichever
study it was about three years ago when I first saw it that you had a
basically 30 percent greater chance of not developing an addiction if
your parents talked about not drinking and not using alcohol.

I thought, my gosh, I know I can think of 100 people I know who would
love to know that something they were saying and starting young could
actually make a big difference. I think alcohol is accepted, it\'s not
considered a drug in our society.

They think it\'s the norm, and what can I do? What can I do? Well, just
knowing that conversation is huge. So I thank you for doing the ad. I
didn\'t realize the federal government couldn\'t pay for these ads.

MR. WING: Well, I don\'t think it\'s a matter of whether we can pay for
them. It\'s a matter of whether the money is appropriated.

MS. DIETER: Yes. That it hasn\'t been appropriated. I guess we should
work to have that appropriated, because I think it\'s just shocking.

MR. WING: What you just said is reinforced through the focus groups that
Alvera mentioned, that the Ad Council did with the parents. They didn\'t
think their kids were doing it. They didn\'t see it as much of an issue,
as long as they weren\'t drinking and driving.

They were very surprised to hear that there might be permanent damage,
that if they started drinking young, that they were more likely to have
an alcohol problem later in life. Which is, as Alvera said, why those
ads zeroed right in on that.

We are hoping that those ads will provoke a lot of discussion in a lot
of homes around the country. We\'re also hoping that these town hall
meetings, one of the things we\'re really hoping is that the communities
that are involved with the town hall meetings will encourage their local
media to run the ads.

MS. HUFF: You know, my daughter went on a skiing trip when she was about
13, and her room was such a disaster, I decided to clean it while she
was gone. I found wrapped in a baby doll blanket in the baby doll buggy
with the baby dolls a bottle of whiskey. Of course I was shocked.

To make a very long story short, she was addicted to cocaine by the time
she was 18, and by the time she was 19, she was selling cocaine. By the
time she was 20, she was selling her body.

So I\'m sitting here like many of us, living proof of all of this. Who
would have ever known at 13 years old wrapped up in a baby blanket was
this bottle of whiskey which would have impacted the rest of her days.

MR. WING: Right.

MS. HUFF: But it is a shameful thing to talk about. I mean, I was ready
when she got home from that skiing trip with every bone in my body
quivering. I might not have ever gone to clean that room.

Even though I did, the outcome was not good. What I didn\'t know is what
we just saw, is that I didn\'t know to compare later, and I didn\'t know
the signs then of cocaine, I didn\'t know the signs of anything.

MS. DIETER: Or to talk about it before she was 13.

MS. HUFF: Or to talk about it before she was 13. For God\'s sake, she
was still playing with dolls.

MR. WING: Well, certainly the alcohol data embedded in our society is
not new. That goes back to, it actually goes back to the Greek, and I
won\'t bore you with that. But it is at least 2,500 years.

That said, we do know so much more now than we did 10 years ago, the
science and the impact on the young. I think we can probably start to
draw some parent\'s attention to it. So I am hopeful of that.

DR. GARY: I just wanted to say, too, that I am most appreciative for the
ads. I think they are very excellent.

I wanted to get back to the comment that Theresa made, and also
emphasize the teach-ins and the teach-outs at school, and bring to our
attention, too, that some parents don\'t have the capacity to teach
their children. Some parents are alcoholics and will not teach their
children because it\'s an interception of their own behaviors. So we
know that that is not going to happen.

Some families don\'t have the capacity to teach their children. Some
families don\'t think they have the self-efficacy to do it. For those
families, I think we could come back and focus on what happens in the
schools. It seems to me you have a very solid structure set up for the
schools, and the teach-ins and the reach-outs in the school.

So I would like to know more about that effort, and also to ask if you
have in place any mechanism whereby you can be able to discuss and
describe the impact that the teach-ins and the reach-outs will have on
children in the schools.

I think if you don\'t, a large percentage of children will fall through
the slats simply because they don\'t have the structure at home to
implement what you wish you had with the parents teaching the children.
So I\'d like us to focus on that population of children, too, and to ask
if there is a second tier to coordinate those efforts, which I think are
excellent.

MR. WING: Well, a couple of points. First of all, the Scholastic
magazine has done some evaluation, and has found the materials to be
very well received.

That said, we know that they are not as broadly used as we would hope.
There are many school systems where they are used, and there are other
places where they end up on a shelf. So one of our challenges is to try
to make sure that they are more properly used.

We don\'t have, beyond that sort of evaluation, the kind of fine-grained
evaluation that would allow us to know what you\'re talking about. But I
think it\'s an excellent point.

This note says thank you and good night.

(Laughter.)

MR. WING: As it turns out, I have to leave anyway, because we have a
meeting at 11:00 at the Surgeon General\'s Office on the Call to Action.

MS. DIETER: Can I ask you just one quick thing while you\'re leaving?
Since that fifth grade Scholastic magazine information was so very
successful, had such a great response, why don\'t we do something again
in 8th grade and in 10th grade?

PARTICIPANT: We don\'t teach (inaudible).

MS. DIETER: Yes.

MR. WING: Well, we started with the 5th graders.

MS. DIETER: I recommend that they follow it up two more times or more.

MR. WING: Right. We started with 5th grade, we have moved to 6th, but
we\'ll certainly bring that back to Mr. Curie. No, I agree.

MS. DIETER: I thought about it a lot before this.

MR. WING: Well, we all know about DARE. It was a one-shot thing and it
didn\'t do much good, but the studies seem to suggest that it may
actually have some effect.

MS. KADE: Thank you very much.

So I\'d like for us to move to our next agenda item on the National
Child Traumatic Stress Initiative Program. Sybil Goldman will be giving
an overview, and then we have several presenters. Thank you.

MS. GOLDMAN: I have to say, I found that discussion very interesting. As
the children and families person at SAMHSA, there is a lot of very
exciting things going on in this agency that do provide a lot of
services and information in treatment and early intervention. That\'s a
very important initiative.

I work closely with Steve, because he\'s really the person who is the
point person for us on underage drinking.

I\'m delighted to be here with you at council this morning. At your
request, we wanted to highlight some of the programs that SAMHSA funds
and provides in communities. There are effective programs that work with
children and their families. So that\'s what we\'re going to do today,
put the spotlight on the National Child Traumatic Stress Initiative,
which is really an extraordinary resource that we have in this agency,
for the work that it does across the country.

The network develops effective approaches for treating trauma and people
exposed to trauma, disseminating information about those approaches,
providing training, and providing direct services in communities.

I don\'t know whether yesterday Charlie talked about this, but the
Department of Education, the Secretary of Education, Margaret Spellings,
asked SAMHSA to join forces with them in working with schools across the
Gulf area that had been impacted by Hurricanes Katrina and Rita, and
they asked if we would bring our child trauma experts along with us to
work directly with those principals and with those teachers around the
children in the communities that had been impacted by the hurricanes.

They were extraordinarily effective, and they\'re very appreciative,
because those schools had access to some of the best experts in the
country with some of the things that they were experiencing not only
with the children, but what we found out with the parents as well. So
just one of the many ways that this initiative provides support across
country.

I\'m just going to take a very few minutes to provide a context for our
speakers this morning that focuses really on them and what they are
doing in communities, and then to give you a chance to have some
discussion.

I also wanted to mention that the National Child Traumatic Stress
Initiative is headed up by Seth Hassett, who is the chief of the
Emergency Mental Health and Traumatic Stress Services Branch at the
Center for Mental Health Services. Seth has been doing a lot of work
with his team in the Gulf Region.

Dr. Cecilia Casale is behind me and Dr. Malcolm Gordon, as well as some
other members of the branch, will be here today to also help answer any
questions you might have in discussion.

I\'m just going to skip over these slides quickly.

This gives you, and actually it\'s a little hard to see, I realize, but
this gives you a picture of where our grant sites are for this network.
They are spread across the country.

What the little grid at the bottom talks about, and I\'ll give you a
little bit more information about this, is that there are really three
categories of grants to this initiative. One is the National Resource
Center, and that\'s actually a collaboration between UCLA and Duke, and
then there are what we call the Category II sites, which are the ‑‑ I
always get these confused here. These are the treatment and service
adaptation sites. Again, I\'ll talk a little bit more about that. Then
there are the Category III sites which are the community services sites.
It gives you a picture of how we cut across the nation.

So there are these three funding categories. This is approximately a
\$25 million initiative. This has congressional support, it\'s actually
a congressional initiative. We are very excited that it\'s here at
SAMHSA.

The goals are to improve the quality, treatment, and services for
children, adolescents, and parents who have experienced trauma, and to
increase access to quality trauma services.

I think what is unique about this is that it really does look at all
aspects of trauma. So I just gave you an example about our work with
natural disasters. The trauma initiative was very engaged after 9/11
around terrorism, but you\'ll hear today that there are multiple kinds
of trauma that the centers are dealing with and providing effective
treatment approaches for. Physical abuse, sexual abuse, domestic
violence, community violence, from accidents and from medical
conditions. So it\'s a broad array of trauma issues.

So the Category I center, the national center that I mentioned is at
UCLA and Duke, and also had, and Barbara noticed this, has a contract
with the Federation of Families for Children\'s Mental Health. It was a
commitment made early on that we wanted to make sure that families were
involved at the outset, at all levels of what the trauma center is
doing.

But this center provides leadership, develops and maintains the network
structure, provides technical assistance to the grantees, coordinates
the education and training. It is really the hub that brings these
pieces together.

Then there are the two other categories of grants. These Category II
grants are the treatment and service adaptation centers.

Are these slides in your packet? I\'m not going to go through all of
these.

It lists out a variety of kinds of activities that these centers do.
They are primarily university-based, and they are the ones, and I\'m not
going to go through all of these. They are the ones that develop,
implement, and disseminate the effective interventions in these
particular areas of trauma expertise.

They also play a role in training around these approaches, develop the
products, and they also see how trauma interventions can be adapted to
different kinds of communities. Does something work in rural communities
as well as in urban communities? With different populations of children?
Maybe those in foster care, or those that are in other kinds of
settings.

So it\'s how we learn from what works, and then see how it can be
adapted to other settings and other populations. If you skip over to the
Category III slides, the Category III grantees, the community treatment
and services centers, these are the centers that are actually providing
services in communities.

So that we can take these interventions that we\'re learning about and
support them, taking communities and different childhood systems and
make sure that these are sustained in the communities. The Category III
grantees also do some evaluation of the interventions that are going on
in their communities because they are in different communities across
the country. So again, we represent different populations.

So today what we\'re going to do is focus on examples of two of these
Category III treatment centers that have different populations and
different areas of focus.

Our two speakers today, and we\'re very fortunate to have them here, are
Dr. Elizabeth Thompson, who is the Director of Clinical Services with
the Kennedy Krieger Family Center, which is in Baltimore and does a lot
of work with children exposed to community violence, sexual abuse, child
neglect, so she\'ll be talking about some of the interventions and
approaches there.

Then we have Bob Hartman, who is the Executive Vice President and COO of
the DePelchin Children\'s Center, which is in Houston, Texas. That is a
large, multiservice agency that provides services to children exposed to
a wide array of trauma. But also the DePelchin Center was key in
assisting the evacuees that came to Houston and to Texas and did a lot
of training of the shelter workers around what to look for in terms of
the children that were impacted by Katrina and by Rita.

So these are people who are very much on the front lines and we\'re very
happy to have them with us today. After they present, we\'ll have some
time for discussion.

DR. THOMPSON: Thank you. I organized my presentation to sort of talk
about life at Kennedy Krieger Family Center before SAMHSA and life at
the center after SAMHSA.

Kennedy Krieger Institute is a facility in Baltimore that has an
international reputation for providing services and improving the lives
of children with developmental disabilities, pediatric developmental
disabilities. The Family Center is one of 40 outpatient centers that
come under the Kennedy Krieger Institute umbrella. We were established
in 1985, and the original mission of the Family Center was to meet the
unmet mental health assessment and treatment needs to children who were
in the foster care system that did not have services being provided to
them.

As we began to work with the children in foster care, what we quickly
discovered was that not only were these children in foster care, but
these children had also experienced a great deal of sexual abuse,
physical abuse, and maltreatment, domestic violence, and community
violence.

So as the Family Center began to develop programs, we sort of broadened
our scope beyond the original mission of working with children in foster
care, and ended up developing programs and responding to children and
families that had been impacted by violence.

When we started about 20 years ago, 100 percent of our children that we
served were in foster care. Today that amount is about 50 percent. So it
is not as large as the original population when we originally started.
But clearly foster care still represents a large segment of who we
provide services to.

Prior to our involvement in SAMHSA, there were a lot of things that we
were very proud of. We had established a real expertise in the community
of working with chronically traumatized children. These are children who
not only experienced a single trauma, but kids that experienced lots of
traumas over a long period of time. That was the area that we had a
great deal of expertise in, and a lot of clinical knowledge. We had
developed our programs in an effort to be responsive to this population.

Another thing that we were doing very well I think before we received
the SAMHSA grant and became a part of the network is that we developed a
lot of specialty clinics. So, for instance, we have a clinic that works
primarily with children that are sexually abusing other children as a
function of their own unresolved sexual abuse issues.

We have a family clinic that works very well with children who are
experiencing children and families who are involved in multi
generational trauma. So we have these clinics, so we really developed in
ways that allowed us to treat specific population of traumatized kids in
a very focused and organized way.

Both SAMHSA and the network placed a lot of emphasis on cultural
awareness and service delivery, and this is another thing that I think
we were doing well before we received SAMHSA. From the moment I
interview a potential staff person, we talk about the importance of
cultural awareness in service delivery, staff are expected, it comes up
in supervision. It is actually part of the written performance
evaluation. So it is not something that we just pay lip service to,
it\'s infused in every aspect of our agencies. In fact, it\'s one of our
guiding principles.

We also have very established partnerships with child servicing systems,
child serving systems in Baltimore City. The Baltimore Department of
Social Services, we have a longstanding relationship with Baltimore
Mental Health Systems, which is the agency that provide all of the
public mental health services to children involved in the city. We also
have a long-term relationship with Baltimore Child Abuse Center, which
is a single point of contact for all children that are sexually abused
when the abuse is reported, of course. It\'s a single point of contact
for all of those kids.

The Family Center serves approximately 1,000 children a year on an
average of 17,000 visits. In addition to providing services to children
in our clinic, we also have therapists who provide services in four
schools that are located in very high crime areas in certain Baltimore
City neighborhoods. We have therapists who go to the homes for clients
who can\'t come in.

The next couple of slides will give you an idea of what our population
looks like at the Family Center. As you can see, 91 percent of the
children have experienced at least one traumatic event. I think you can
see that this is sort of a list of the types of trauma that we have
provided treatment for at the Family Center, and some of the
frequencies.

This is just a list of the ones with the highest frequency. We actually
document about 45 different types of trauma. This just gives you an idea
of those with the highest frequency. The average kid that we provide
services to has experienced three traumas. Not necessarily on this list,
because this is not an all inclusive list, but the average kid has
experienced three traumas.

We actually have children who have experienced 10 and 11 different types
of traumas. So that begins to give you a picture of the kind of children
and families that we\'re working with.

This is a list of parental issues. This is a percent, this slide is
really birth parent issues. The thing to keep in mind is that we have
children in birth families, and we still have a significant portion of
our children who are in foster families. But you can begin to see some
of the things that are critical to look at and understand in terms of
working with children that have been traumatized.

Not only are the children traumatized, they come from primary families
that have a set of issues that pose additional risk factors.

To kind of give you the story of our involvement with SAMHSA and the
network, to take you back a few years before we were funded in \'03,
probably around November or December of 2001, we began at the Family
Center to make a very purposeful and strategic effort to improve our
program in certain areas.

One of those is we decided to improve upon our outcomes evaluation
system. Another thing we decided to do was to begin using treatments
that dealt with the neurobiological impact of trauma. A third thing that
we decided to do was to encourage our staff to integrate research into
clinical practice in a more deliberate way.

Probably in early 2002, one of the things I did in terms of trying to
change the culture was it was somebody on my staff\'s responsibility to
review the trauma literature that was coming out in academic databases.
At some point she discovered that there was this trauma network. Of
course we made some phone calls and somebody said it is too late, you
can\'t get it in it, it is already set.

I remember how disappointed we were, because even at that time, we felt
like we would have been a really good match for the network because of
the things that we were doing, and because of the things that the
network was doing.

At that time, I didn\'t know that this was sort of rolling funding, so I
had no idea then that we would get another opportunity. In 2003 when the
RFA came out, this is a true story, within five minutes, three people on
my staff emailed me and said, Elizabeth, look, there is another chance,
we have to go for this.

Interestingly enough, I hope this is okay to say, I\'ll say it. It is
the only time that I have ever been involved in a grant writing process
that I was actually pretty confident the whole time that we were going
to get the grant. That\'s how strongly I felt about the match that our
program was to SAMHSA.

Of course we were funded in 2003. Because of the support from SAMHSA
both in terms of the funding, but also in terms of the regular contact
and the support and the network collaborative structure, we\'ve been
able to improve the standards of care and access to services in
Baltimore City.

I want to say a bit more about the network collaborative structure. I
believe it is the network collaborative structure, that\'s one of the
things that makes the network work so well. It\'s the collaboration.

It\'s funny. I told my daughter I was going to be nervous this morning.
She asked me, don\'t forget to have water with you, because when you get
nervous, you have a dry mouth. Interesting, even though she\'s a
13-year-old in the 8th grade. You can bet the conversation I\'m going to
be having with her when I go home.

(Laughter.)

DR. THOMPSON: So it\'s not just 45 different agencies doing their own
thing coming together once a year. There really is strong collaboration
in an ongoing way. We share resources, we submit data to a common data
pool. Phone conversations, email conversations, meetings, so the
collaboration I think is really key. You get to form relationships and
sit at the table with other experts in the field of childhood trauma.
That\'s a pretty unique setup.

Raising the standard of care. While this slide, I want to divert just to
give you one example. We have really seen improvement since we\'ve been
in the network in terms of individual therapy, in terms of my own
program at the Family Center, and also the impact that we\'ve been able
to have on Baltimore City.

Just to give you an example, one of the members of my staff who is
fluent in sign language joined one of the network\'s working groups. It
is called the Adaptive Treatment Standards Working Group for children
with disabilities.

The purpose of the working group is to look at how treatment can be
adapted for children who have special needs. So she joined this
workgroup, and she was fluent in sign language. She came to me probably
within a month of joining and said Elizabeth, can we start a clinic
where we provide trauma focused services for children and families who
are deaf and/or hard of hearing?

So you attempt to go through the fiscal part of it and how you\'re going
to do it, and the operations piece. Of course I said yes. We have had a
tremendous response. There were people providing mental health services
for children and families who were deaf and hard of hearing, but of
course nobody was providing trauma focus. So that is a perfect example
of how based on a collaboration from the network, we were able to
improve services in Baltimore City.

So impact on KKFC culture, one of the things that we thought we were
doing a pretty good job was around incorporating families in treatment
at the Family Center. Of course we found out, as everybody I\'m sure
knows, both SAMHSA and the network placed a really high priority on
engaging families.

This was something we thought we were doing a pretty good job in. But we
tended to view engagement primarily in terms of engaging families in the
treatment process. Of course that\'s just the first step.

One of my staff again had the opportunity to join a network working
group, it\'s the Consumer Engagement Working Group, and I think to this
point the culmination of this group\'s effort was a consumer engagement
conference that occurred in October, I think. That\'s where the
Federation of Families was critical in helping the network develop that.

One of the things that two members of my staff who attended that were
most excited about is that there were 50 percent consumers there, and 50
percent professionals. Of course that\'s unusual, because a lot of times
you go to these conferences and people pay lip service to having
consumer involvement, but there is a room full of professionals and then
two family members sitting to the side that they bring on.

This was a conference where over half of the people there were
consumers. I think one of the neatest things that one person on my staff
said, you didn\'t know who was who. That\'s pretty powerful.

What we began to realize is that engaging families in treatment is just
one piece of it. It\'s really more about engaging families as real
partners in program development and service delivery.

We made a decision a couple of months ago to make this one of our
strategic planning goals to ensure that it stayed on the front burner
and we didn\'t lose track of it. A good example is that we recently
decided to start implementing biofeedback and some similar kinds of
techniques. Before developing the program, we decided to engage a group
of care givers to help us decide how we should develop the program.

That really is a first for our agency. It is just the first step. We
have a long way to go, but I think it was very important, and I\'m
certain had it not been for our involvement in the network and hearing
SAMHSA and hearing the network talk about it and making it a priority, I
don\'t think we would have done so in our own organization.

Staff improvement. Adoption and adaptation of best practices. Of course,
and this kind of gets us into the conversation of evidence-based
treatment. Evidence-based treatment is not the only avenue to quality
mental health, but it clearly is an important one.

One of the things that we paid a lot of attention to are evidence-based
practices. Now, one of the things I think it\'s important to know about
the network is that they have a learning model or an approach to
training that goes way beyond just this single shot training where you
go in and you train somebody on a new technique, and you leave and you
don\'t know if they learned the technique, if they\'ve implemented it,
if it had any impact.

The way the network views training is that it is an ongoing process.
There really is a commitment to knowing that not only have you learned
what you have been trained on, but it has been implemented and
implemented effectively.

One of the ways we have seen this in the network is our work around
learning trauma-focused cognitive-behavioral therapy. Trauma-focused
cognitive-behavioral therapy is one of the best practices. There is a
tremendous amount of evidence that says that trauma-focused
cognitive-behavioral therapy is very effective with children and
families that have been traumatized.

So we started with a single training in Allegheny, as a matter of fact,
we went to Allegheny Hospital in Pittsburgh, which is a Level II site
where trauma-focused CBT was developed.

Subsequent to that initial training in Pennsylvania, the network
established regional trainings around the country. My staff attended the
one that was in New Jersey with a Level II site. After that second
training, there were these monthly consultation calls, and then an
advanced training.

So you get the idea that it\'s not, again, not a one-time thing, but
it\'s training and follow-up, and a real commitment to knowing that
clinicians have really learned the model in a way that it can be
implemented effectively.

The phase that we\'re in now is the National Breakthrough Series
Collaborative. The important thing about the Breakthrough Series
Collaborative is that it goes beyond the individual clinician learning
trauma-focused CBT, but it is helping us understand how does
trauma-focused CBT get implemented at the organizational level. So it\'s
about identifying barriers and solutions to those barriers that enable
us to implement it at the organizational level.

How does the community get involved? How do judges and other people who
refer children to your agency kind of understand trauma-focused CBT?
What are the fiscal issues that impact? What are the therapist\'s
attitudes that impact the ability to implement this?

We like to think of ourselves as change agents in the systems that we
work with. One of the things we were able to do with our SAMHSA dollars
is that we established a training budget. We have been in the network
now two years, we have conducted about 24, 25 trainings. We have
actually trained about 800 people, parents, police officers, pediatric
residents, school teachers, DSS workers, a host of people on how to work
more effectively with traumatized children and families in their service
sectors.

So how does a school teacher do her job more effectively if she is more
trauma informed? How does a pediatrician do his more effectively, and so
forth and so on. I didn\'t watch my time.

MS. GOLDMAN: Three or four minutes.

DR. THOMPSON: Three or four more minutes. Okay. Let\'s see what I\'m
going to skip.

MS. SULLIVAN: That never works for anyone. Just go ahead.

DR. THOMPSON: Thank you. It is because I actually timed this.

MS. SULLIVAN: Just go ahead.

DR. THOMPSON: Thank you.

The community advisory board is something I\'m really proud of. Again,
the community advisory board is post SAMHSA, it has a team who received
treatment, have completed treatment, two teams in fact and a couple of
care givers on this board.

They, as well as the agency that I mentioned earlier, they are on the
board also. What they have told us is that their involvement with our
center, they are more trauma informed, we have helped them develop
training in their own centers.

One of the messages we have been able to get across is that when you
work with traumatized children and families, it is not enough just to
have a general mental health background about children, you need to have
a very focused and specific background as it relates to trauma. You also
need to be aware of best practices.

It is a focused approach, and trauma is right there on the table. We
used to think it would take a year to develop a relationship, and it has
gone on and on and on. Now it\'s clear that it is much more focused and
much more direct. You need training to understand that.

The product development, the network really is into developing products.
A couple of people on my staff have been involved in developing a
product for child welfare professionals that teaches them how to be more
effective in their job. This is something, there were about 12 or 13
sites involved with this child welfare product.

To give you an idea, 13 people involved in the development of a product,
if you think of that many agencies and people being involved, and doing
a lot of the work in conference calls, too, you can kind of begin to get
a sense of how things develop.

The reason this accelerated is because the network made its decision
that this was a product that they wanted to push along and get out very
quickly. The Public Policy Roundtable provided us an opportunity in
Baltimore, what the Public Policy Roundtable was is they were
representatives of 15 states, the network project director, as well as
the person responsible for Department of Social Services, and the person
responsible for children\'s mental health in the state.

Because the roundtable was actually held in Baltimore, we had an
opportunity to bring together the Director of the Department of Social
Services, who actually has since resigned unrelated to this Public
Policy Roundtable, but we had an opportunity to bring him together for a
first meeting with the person who is the Director of Children\'s Mental
Health in Baltimore.

That\'s an opportunity that we would not have had. I don\'t think we
would have gotten presented were it not for the Public Policy
Roundtable.

A public awareness campaign, improving access to services. There are at
least a couple of ways to think about improving access to services. One
is you can look at the concrete things like transportation, cost,
location, and some of those kinds of things. Another way to think about
it is in terms of people\'s attitudes about service and mental health,
and whether or not they seek them out based on their attitude and
stigma.

So our community advisory board decided to attack public awareness from
this perspective. I\'m sorry, to attack access from the perspective of
public awareness. What were people\'s ideas about trauma and how did
those ideas either lead them to or away from seeking treatment.

So we actually hired a professional facilitator and conducted full focus
groups in four Baltimore City schools with care givers and a Head Start
program. We found out, not surprisingly, that these were the four
neighborhoods that a tremendous amount of community violence where kids
don\'t even go outside during recess time because of gunfire in the
neighborhood.

So it is hard for me to imagine going to school and not being able to go
outside for recess because of gunfire going on. So these were the
neighborhoods that we conducted the focus groups. Not surprisingly, when
people asked what is trauma, they thought death was trauma. The teams,
as well as the adults thought this.

The teams were pretty clear that we needed to develop a teen campaign
and an adult campaign. They felt like a message targeted towards adults
would not be the same message that you needed to use towards teens. But
the teens and the adults felt like death was what trauma was.

They also believed that this was a normal part of growing up. A
significant amount of the care givers believed that living in these kind
of neighborhoods sort of prepared children in a positive way for life
later on. So there was a real normalization of the trauma that they had
experienced.

I\'d like to end with just a brief word about some of the work that
several of my staff did. We were asked to go to Anne Arundel County to
work with a group of teenagers that had been relocated because they had
experienced Hurricane Katrina. So we were asked to come and do a
one-time group to work with children and teens that had been
traumatized.

So the teens were given the choice of either choosing an art project or
a verbal project, something written. They chose the written project.
What the assignment was, they were given a choice of eight words, and
they were told they had to choose five of the words, and then they had
to create a poem. A poem with five lines, five stanzas. The entire poem
had to have five stanzas, and each stanza had to have five lines. They
had to use each word on a rotating basis within each stanza.

It included a word or a line that the entire group had to agree on. So
the words they chose, because of the work that\'s being done in the
network, healing and recovery occurring in a better way now than it was.
But nevertheless, trauma changes you forever.

The second lesson is that we can never lose sight as mental health
professionals, and I\'m an administrator now, but I started out as a
mental health professional, and as a mental health professional we can
never lose sight of the hope and resiliency that families glean when
they come to us for treatment.

\"Strength is a powerful thing. Miss our friends, hope to return, life,
glad to have it. Change is hard. Miss our home room, hope to find
missing people, life for the future, change for the better, strength to
carry on. Hope for life, life is different, changing friends, schools,
culture, strength from my momma, miss the flood, life should be withheld
with love, change is versatile with good or bad.

\"Strength from people that believe what you do. Miss Mardi gras, hope
that people\'s pride will stay alive. Change is a blessing in disguise,
strength from living in New Orleans. Miss school, hope from God, life
should be cherished. Love with open arms, love is an obstacle and
confusion.\"

The group decided at the end, my thought as being teenagers, that after
agreeing on the five words, there were a couple that wanted to add the
last stanza. So they decided to end with \"Again, love with open arms,
love is an obstacle.\"

Thank you.

(Applause.)

MS. GOLDMAN: Thank you, Elizabeth. I think your presentation really gave
a wonderful picture of not only what you do with teens, but how you are
touching people\'s lives, how you really have connected to this whole
network, and how it really does support our work. That\'s what we\'re
hoping will happen.

Bob, do you want to take it?

MR. HARTMAN: Thank you. Wonderful, Elizabeth.

DePelchin Children\'s Center is one through 12-year-old agency in
Houston. Houston is the fourth largest city in America, so we have also
grown to be a large organization with an array of services. We have
services that ‑‑ Kennedy Krieger actually span from early intervention
services to mental health counseling because of the merger early on with
the Child Guidance Center to services for homeless moms because we\'re
affiliated with the Florence Crittenton Center in Houston to home-based
and community-based therapy services to therapeutic foster care,
residential, intensive residential treatment services, and additionally
an option for children who are in foster care to post-adoption support
services for those families.

I liked Dr. Thompson\'s statement about prior to this grant and after
this grant. For the last 20 years, we have been very active in writing
grants for state and federal initiatives. We are 80 percent successful
in landing grants. We have a large research and grant management
department that tracks our grant activity.

This grant was so different. This became a catalyst for transformative
change for us.

Just on a slide here that talks about our goals, we actually mirror
SAMHSA\'s goals and what they\'re wanting to achieve for the trauma
initiative. Increasing accessibility. Developing for us a community
network of professionals to do that access to care.

We wanted to become a learning organization. We knew that though we
serve about 27,000 children and families each year, about 5,000 of these
kids have experienced multiple and complex traumatic incidents. We see
that this cuts across all of our services as well.

We wanted to of course improve outcomes for kids and translate research
that we are seeing in the network into our own practice.

I will talk briefly about some of the accomplishments we\'ve been able
to achieve over the last two years with this grant. It has only been two
years, which is amazing. We hit the ground running when we were awarded
this opportunity to serve children in this different way.

Rather than reading through all of these various accomplishments, let me
highlight a few. Media placements and media response. I\'ll be talking
more about our agency\'s response to the Katrina and Rita hurricanes in
a minute. But one of the media placements, if we can pull it up in a
minute, is ‑‑

MS. GOLDMAN: This is a Word document that they\'re switching to a DVD.

MR. HARTMAN: Then we\'ll wait for that media placement. Hopefully that
will come up for us. That\'s a PSA that we developed for the Katrina
evacuees.

One of the first things we did was we established an internal core
trauma team. We saw this group as being the ambassadors internally for
change, to change our culture, to become a learning organization.

We had 15 people from different departments within our organization come
together monthly to plan, to prepare, to learn, and to disseminate
information to each other throughout our organization.

We also established a community trauma network so that we could be a
part of training, and to disseminate materials that SAMHSA and the
National Child Trauma Stress Network has been sending to us. Over 200
organizations have become involved in this. We have been able to provide
78 training sessions for over 2,500 people just this last year.

This is all new to us. We hadn\'t been doing this kind of thing in the
past. We have actually put network counselors on our website so that
there is increased access for people if we are busy, if the location
doesn\'t fit them, then those people around the community are available
as well.

In terms of our NCTSI collaboration, we were nervous about this
initially because everyone had said jump in and be a part of the
national network. We had so many different services that seemed to
relate to all the task forces. We cautiously put our foot into about
five, and then in the last eight months or so, have expanded to foster
care workgroup, Data Corps, Public Policy Corps, school intervention,
system integration, residential workgroup, training, and Data Corps.

It really has been impressive, the information that we have been able to
share, the information we have been able to glean from these
opportunities to connect with our network.

We\'ve developed papers around financing for a child welfare service,
monitoring psychotropic drugs in the child welfare system, workforce
issues in implementing trauma care, as well as how to establish a
community collaboration around trauma services.

The training has been very supportive, as Dr. Thompson mentioned
earlier. We have been involved in a trauma-focused cognitive-behavioral
therapy parent/child interactive therapy. That, by the way, for us was
interrupted because of the Katrina hurricane. We couldn\'t participate
in the second round of that training, but we are planning to do that
later.

The sanctuary model for residential care as well. I\'ll share that
experience with you, that the intensive residential treatment center
entered a partnership as a result of this trauma network with the
Department of Family and Protective Services to determine if we could
better serve kids in our residential care who are specialized in intense
needs, and then can those kids move on to therapeutic foster care
environments and be sustained there.

We changed the culture as a result of this sanctuary model implemented
in our center. Let me just share with you some of the statistics
regarding that. Twenty-four percent of the kids that have come to us
have higher level needs. So we see that the department is seeing us as a
resource for some of the hardest kids, kids who have been to other
residential care facilities prior to coming to DePelchin.

Sixty percent of those kids discharged from the residential care have
moved to a less restrictive environment. We have been able to see 87
percent of those kids stay in their therapeutic foster home or move onto
their birth families, or to an adoptive placement.

We have lowered the length of stay 50 percent compared to the state
average. We are seeing now an 89 percent reduction in restraints and
seclusions. We have a residential center that houses about 40 kids. We
stay full with about 38 as an average.

Prior to starting this initiative, we were restraining kids and
secluding kids for disruptive behavior about 51 times per month. Now we
are about five per month, way below the national average of around 20. I
think you have to look at 1,000 days, the number of kids in care over
that length of time. It is just truly remarkable.

Texas calls a hand holding onto an elbow escorting out of a room,
calling that a restraint. We have actually been able to shift much of
the restraint activity to an escort to change direction for a child. We
credit this to our work within the trauma network.

There is a portion here that says translated research into practice. One
of the successes is advocating for a major change in the child welfare
system in the State of Texas. Senate Bill 6 was passed this last year.
We actually hired a Director of Public Policy Government Relations, and
as a team, we testified in Austin for compassionate care for children,
for systems to be more integrated for their care, for case management to
be more continuous, and for the trauma that every child in foster care
has experienced to be dealt with adequately, and the legislature
certainly accepted that.

Let me move then to a more dedicated effort when Katrina at the end of
August, early September, began to impact Houston. For us, we are so
fortunate that we had been a part of this network for almost two years
at that point. We felt ready to be a part of the solution around this
major issue.

Just to let you know, we receive calls often from our SAMHSA staff
liaison from the National Child Trauma Stress Network and they say how
are you doing? Are you holding up? How is it going? I can share that it
has been chaotic, overwhelming, confusing, exhilarating, challenging,
and heartwarming and heart wrenching.

We made a priority decision to put aside many of our priority activities
to focus on Katrina evacuees. That has been a very important step for us
in responding to the care needs. However, you can\'t put aside 400 kids
in foster care, now almost 50 kids in the residential center. We have
another residential center as well. Those needs and those services go
on.

Let me just share with you in terms of direct service response, we are
immediately responsive to the kids who were at the Astrodome, there were
about 25,000 families, people at the Astrodome within about an 8-day
period. People streamed in on buses as you saw on the national news. The
George R. Brown Convention Center had 5,000 people.

We have a relationship with Baylor School of Medicine, School of
Psychiatry, and also the psychology department where psychologists are
interns at DePelchin. These doctoral candidates and post-doctoral
candidates, we deployed into the large centers for counseling round the
clock shifts, as well as our psychiatrists. We have six different
psychiatrists that work with our populations.

We have received 20 referrals for foster care placements. We have worked
with the Covenant House from New Orleans who have come to Houston
working with 74 of those kids and about 25 staff members from Covenant
House for counseling and support. We have assisted the schools with the
two schools, new schools, that Houston independent school district set
up for these kids who have been evacuated, as well as 50 other schools
around the Houston area with counseling, consultation, and training.

Let me tell you a real touching story that occurred with a homeless teen
who came from the Covenant House connection in New Orleans. She was
about ready to deliver right before Katrina. She got on the bus, came to
Covenant House. We had actually a set of apartments on our campus for
homeless moms. We have a transitional living program to help young
families.

We were able to bring her into our program. When she then gave birth, we
helped. We were the breathing coach in the hospital. One of our managers
was at a national Florence Crittenton Center conference connected with a
Crittenton Center in Montana that wanted to be a part of this solution.
They offered to start a new life for this young woman, Adrian, and her
daughter, Dominique. We really thought that she would call her daughter
Katrina Rita, but she didn\'t do that.

This Crittenton Center has taken this young family in, and is now caring
for her needs. That\'s really exciting to us.

Well, there are many more incidents of direct service. The State of
Texas allowed our home and community-based therapy program to
incorporate the funding, access, and the intake process for that
service, and we have been able to serve 120 families just through that
same process that we have been serving.

Just recently we have been able to work with the Houston independent
school district to sign a major contract that will allow us to provide
individual and group therapy sessions with kids, group experiences for
families, and this is where the engagement of families is going to be
very critical. We\'ll set up family council around deciding what kind of
support people need, and consultation and training within schools as
well.

We were able to coordinate and communicate with the national network,
responding to their calls. We distributed the psychological first aid
packet that was just out at that time, as well as a trauma screening
tool. Fortuitously when Katrina hit, we had been planning a regional
training conference on child traumatic stress.

The state director, or assistant director of behavioral health, Dr.
David Wanser, I believe called Charles Curie, who then connected with
staff members and put everybody in touch with the NCTSI site at Houston
to help train, as Ms. Goldman mentioned, the center staff that were
dealing with sexual abuse issues in their centers, that were seeing
child abuse and neglect and didn\'t quite know how to deal with these
issues.

So we were able to add workshops into our conference so that those
people can participate. That was just marvelous.

In terms of public awareness and response, we received calls from
\"20/20,\" \"Nightline,\" \"Paula Zahn Now,\" the AP, all the local TV
and radio stations, Houston Chronicle, New Orleans Times. It truly was
an overwhelming time for us. We have a marketing department that worked
with the national center here that was able to triage these and provide
points of discussion that helped us deal with this.

I don\'t know if it\'s possible to see the PSA that we developed, that
we could show.

(PSA shown.)

MR. HARTMAN: We have an access department with six telephone operators.
Our calls have gone to 1,600 calls per month since Hurricane Katrina as
a result of these ads and other kinds of activities we\'ve done. We are
now receiving about 96,000 calls per year.

During our response to Katrina, Rita was offshore, and Rita was heading
towards Houston. We had then to prepare for our own evacuation. We
evacuated 200 kids from foster homes with the foster families. We were
tracking where they went to make sure that they were safe, and provide
consistent care, as well as our residential treatment centers, we wanted
stability there.

But our training and trauma care had us thinking we\'re going to now
require foster parents to sign an emergency plan as part of their
preparation for foster parenting in case something like this happens so
that we all know what process to go through.

In terms for us for the future, trauma care, especially after a
hurricane, there is an immediate response for psychological first aid,
and then there is a longer, slower kind of trauma build up that kids
begin to experience and show later on.

Now that families have calmed down enough, we are seeing a lot more
disturbances in schools, whereas initially everybody was in shock. They
weren\'t displaying the trauma that they experienced. We know that the
access points for us will be the schools, public health departments,
pediatrician\'s offices, and daycare centers. That would be kind of a
front line noticing what kids are needing.

Our board has recently gone through a strategic planning process and
realized that this grant has transformed the way we provide service. It
is a cohesive type of initiative that if you read Jim Collins\' book,
\"Good to Great,\" it\'s a hedgehog concept for us. Therapeutic care for
kids, especially in the child welfare system.

I think I will end there. You have the material in front of you. But I
just want to express my appreciation for the work that SAMHSA has done
through this and the National Trauma Center.

I think we\'re open for questions.

(Applause.)

MS. GOLDMAN: Yes, we\'re open to questions to both of our speakers here.
As I mentioned before, we have staff here from the branch, Dr. Gordon
and Dr. Casale, who can answer your questions as well, or myself. So
it\'s open.

Toian reminded me that you all have to be out of here by noon sharp.
There also needs to be an opportunity for public comment, so we will
have to watch the time for those events.

Barbara?

MS. HUFF: First of all, thank you very much for your presentations.

I wanted to just make a comment to you, Dr. Thompson. I wanted to just
say in sympathy (inaudible) family guidance in the child welfare system,
and it\'s really good It might be a nice companion to what you\'ve
developed. It was developed over a year time and it will be on
Georgetown\'s website because they were instrumental in doing a lot of
the work on it. Families also were part of the development of that,
which I know you all appreciate. So that\'s just an FYI.

Then Bob, I wanted to ask you, in the reduction of seclusion and
restraints, you gave a lot of credit to the trauma center. Is that in
training? Or tell me about that. I want to know what it would take them
to get the other 5 percent of seclusion restraint gone, if you think
that\'s possible.

I think we have a lot to learn from people who are actually trying to
reduce seclusion restraint, because this has not had a successful entry.
So could you speak to, you said you gave credit there, but you didn\'t
say how that happened.

MR. HARTMAN: It was a very focused effort by our administration to
review every single restraint, to track it by time of day, by child, by
staff member, by length of time of restraint, the type of restraint.

We had a weekly meeting established around this. Lots of training. A
different way to talk to kids. A residential center tends to want to
control kids so that they don\'t get out of hand too quickly, because it
can be kind of an explosive environment with kids with very specialized
and intense mental health needs.

So we began talking to kids differently, and preventing and anticipating
the need for restraint to help staff recognize their own emotions prior
to reacting to an issue, and involving teams of staff so that if
somebody is hooked, then you turn to the other staff member and say will
you please work with us?

We debrief and we plan with each child and with each staff whenever
there is a restraint. We told staff early, we will gladly give up a
chest of drawers, but we don\'t want to retraumatize a child in
restraint. So we\'ve had more property damage, and staff has to allow
that to occur.

No, we wouldn\'t allow that in our own family, but these kids are not
normally in families in this kind of way. So it has been a process now
for about a year and a half. I don\'t believe it is possible to fully
reduce all restraints, because you want to protect kids. Some of these
are in response to a child harming himself or others.

So typically now we see it focus on a few kids who have the most
restraints, and we begin looking at their case plan, that will allow us
to be a step down for them, and for them to be a respite for some of our
kids as well.

MS. HUFF: I congratulate you.

MR. HARTMAN: In a nutshell, that is kind of how we address that.

MS. HUFF: (Inaudible.)

MR. HARTMAN: Well, and we just realized these are not bad kids. They
have had bad things happen to them, and they are reacting in some
behavioral way to something that happened years ago. We realize that
this trauma squirts out in unusual ways at different times in a kid\'s
life. That\'s what we\'re seeing as staff. So they\'ve learned more.

So the therapy, we have therapists there. Therapy has really shifted
from the therapist to the youth care workers who develop the
relationships with the children, we recognize that.

MS. HUFF: Thank you.

MS. GOLDMAN: I think that centers and providers that have made this kind
of conversion are the best way to train others about how to do this.
Seclusion and restraint is one of the major kinds of traumas that kids
would be experiencing, so maybe there is a way to do some of this kind
of training through the national network.

PARTICIPANT: Can I ask a question or save it for public comment?

MS. VAUGHN: No, I\'m sorry. This is just for the council.

DR. GARY: I want to commend both of you. I found the presentations to be
enlightening, but also informative. I wanted to also comment about the
therapeutic approach that you are using, and the sense of commitment
that I sense from both of you, the sincerity of the work that you do.

I just wanted to follow up and make a comment about the networks,
because I think if you look at the networks, you could coin the networks
and call them invisible universities, if you will, because the networks
indeed embrace a certain perspective and provide the evidence, but also
provide the strategies and tools, the behaviors that must change in a
staff in order for it to work.

In a sense, you have created your own invisible universities. The next
question would be then how is it that you can continue to impact other
facilities that may not be in the network that are located all over the
United States, and invite them to become a part of the network so that
you can educate them with the knowledge that this invisible university
now has.

That\'s the first observation. The second observation is I find the area
of seclusion and restraint a very dynamic one, because it is a judgment
call. It is a judgment call that\'s made by staff. It is based on
staff\'s previous life experiences also. You did not address that point.

So I wanted to ask if you would address how you assist the staff in
handling their own trauma, and their own anxieties, their own fears and
frustrations about aggression. Aggression is conceptualized quite
differently when you look at ethnic minority males. You look at Hispanic
males and black males and aggression, you\'re into a very different
realm. How do you address those issues with your staff?

MR. HARTMAN: Wonderful reflections. A couple of things regarding
training. We have been, and I believe Dr. Thompson as well, have been
active in our own national networks of service. Child Welfare League of
America, the National Alliance for Children and Families, and on the
state level as well, the Texas Alliance, which provided multiple
training sessions around these kinds of issues that we\'ve talked about
today. Those will just increase.

We met last week with the Department of Family and Protective Service
senior staff, as they are looking at the privatization initiative around
child welfare, and offered the opportunity to train around seclusion and
restraint and trauma-related care in integrating systems of care that
make sense for kids so they\'re not retraumatized.

Regarding staff, that\'s a very good point. We have changed the way
we\'re interviewing staff at the beginning of the hiring process, and
talking very much specifically about those experiences and how they
respond to people getting angry and people using language that might
hook a certain reaction.

Then it is a subject of staff meetings, of the debriefing sessions after
each restraint so that we help and nurture staff so that they have begun
to change. We have a core staff of probably 15 people that have been
there an average of between 10 and 12 years. So they have made a
dramatic improvement. These aren\'t new people that we\'re hiring into
it.

So it is working with those ways they used to work, and changing that
culture.

DR. THOMPSON: And I\'d just like to add a couple of comments to that.
Your remarks sort of triggered two things in me.

The first is the comment about aggression and staff history and how that
impacts their ability to deal with it. Two things that we do at our
agency. We have a secondary trauma support group, because one of the
things we are very aware of is that when you work with kids that have
been traumatized ‑‑ your own history then because of the impact of work,
you have to be careful, thoughtful, and promote self-care, because they
are also impacted by the trauma.

So we have an ongoing support group with therapists who talk about that
that actually doesn\'t have any administrators or supervisors in it,
because one of the staff, you know, felt like they would be freer to
kind of talk about those kinds of issues when there wasn\'t an
administration person there.

The second thing was the issue of cultural awareness. I think when you
talk about African American males and Hispanic males, you are absolutely
correct that you start treading different territories. One of the things
we\'re clear about is you have to be aware of this from a cultural
competence perspective. So we talk to staff about that.

We do a lot of adolescent male groups, and I have had staff who have
been fearful because the males are taller than they are, and are bigger,
and interact with each other in a way that 85 percent of our staff is
African American, and only about 20 percent of my staff is African
American.

So for us, it\'s something that we address on an ongoing basis.

MS. GOLDMAN: I\'d just add one, Dr. Michael Wong, who is with the
National Center when we were doing the visits to the schools across the
Gulf, she talked a lot about compassion fatigue and how much work you
have to do with all of the care givers and providers, whether they are
teachers or whether they\'re the workers in your centers, and how much
support they need.

She also made the analogy of the airplane when they say put your life
mask on first before you help your child, that the same thing is true in
terms of any of these centers where we are providing services, that a
tremendous amount of support has to go to the staff, because this is
very hard work, and they need that kind of help.

MS. DIETER: I don\'t really have a question. I just wanted to thank you
both for what you\'re doing. This morning for me, your reports were
particularly impressive, because they embodied a sort of evolution of
your centers.

I don\'t think that\'s always the case. People you hear from talking
about a project they\'re doing, your sincerity is wonderful, and also
sort of a very thoughtful openness to change and development of
improving things all the time. It was very impressive. Thank you.

MS. GOLDMAN: Any other questions?

(No response.)

MS. GOLDMAN: Well, I just want to personally thank both of you, Bob and
Elizabeth, for excellent presentations, and also for the staff that I
have the honor of working with at SAMHSA who head up this program. I
think it has made some extraordinary advances, as I said before, in
terms of what we\'ve learned about trauma and treatment.

Also for your request to hear about programs, because it is so easy as
we give out grants and project officers for all of these different
efforts that are going on in communities, not to focus on what it is
that these grants are supporting on a day to day basis that helps
children and families and people struggling with addiction and other
mental illness. That\'s really what SAMHSA is all about. So thank you.

MS. KADE: Thank you very much.

(Applause.)

MS. HUFF: I\'d like to say thank you for having such a focus on kids
this morning, and also for hearing us when we said we wanted to hear
from more people in the communities where real services were taking
place. Thank you for hearing that.

MS. KADE: Good. Thank you.

Before we go into public comment and some closing remarks, I wanted to
introduce Mr. Ron Seger, the founder of Race Against Drugs.

MR. SEGER: Thank you. I know that you all are going to break very
shortly. I wanted to introduce you to a program when you talk about
kids. Our kids focus on Motorcraft sports. Our focus is we all look for
something that is going to attract the attention of young people and get
them to listen to our message. It\'s the color, speed, and excitement of
that sport.

We have a program called Race Against Drugs. Four hundred and fifty
thousand of these coloring books, they are activity books, were just
distributed to Texas, Louisiana, and Mississippi by SAMHSA.

When you break in front of the vestibule that you came in, there are
some posters. Please take as many as you wish. They\'re all exciting. We
use subliminal messages. We want children to take them home and put them
on the walls. They\'ll get the message.

When they are watching NASCAR every Sunday, a lot of the drivers that
drive for NASCAR are some of our spokespeople, and we found a long time
ago that as adults, as law enforcement, when we make a presentation, the
kids are fidgety. They\'re doing other things.

When I get a well-known race car driver standing up there, and they
recognize him because they just saw them on TV, they listen.

When you walk out of the building, there is a Motorcraft car sitting out
front. It is one of the cars that we use. We have 24 different
sanctioning organizations that work with us.

I only had a short period of time. Thank you very much.

MS. SULLIVAN: Wait, wait. A couple of drivers, a couple of the motor
organizations, and you said \"we as law enforcement.\" Obviously, you
are with law enforcement.

MR. SEGER: No, ma\'am, I\'m not.

MS. SULLIVAN: Okay. A couple of the drivers and NASCAR and who else?

MR. SEGER: We work with 24 different sanctioning organizations. Most of
their drivers that work with us (inaudible).

MS. SULLIVAN: Indy cars?

MR. SEGER: Indy cars, NHRA, Grand Prix, everybody that is involved with
motor sports.

MS. SULLIVAN: And what drivers?

MR. SEGER: People like Richard Petty, Daryl Walker, Bobby Hill, Jr.,
(inaudible). Those are just NASCAR drivers. The entire Andretti family.

MS. VAUGHN: Would you tell where your car is located?

MR. SEGER: The car is located right in the front of the building as you
walk in.

MS. SULLIVAN: And Ms. Patrick, is she?

MR. SEGER: Oh, Dana Patrick?

MS. SULLIVAN: Yes.

MR. SEGER: We\'ve been talking to her.

MS. SULLIVAN: We need a girl, we need a girl.

MR. SEGER: Thank you very much.

MS. KADE: Thank you very much. You all try and take a look at that car.
If you want additional information, Toian can send it out to you.

We\'re going to open it for public comment. Dan Fisher? Dan Fisher, and
then anyone else who would like to join in.

DR. FISHER: I\'ll be very brief. I\'m the Executive Director of the
National Empowerment Center. I just wanted to report on some work that
we did down in Louisiana so that SAMHSA knows. This was supported by
SAMHSA.

We did two trips to Louisiana. In the first one, they identified they
wanted peer support training among the consumers in Louisiana, so that
they could then provide peer support to other consumers in the affected
areas.

October 18th to 20th, we convened three national leaders to go down and
do training for 45 consumer leaders in Louisiana in New Orleans,
Lafayette, and Baton Rouge. We worked with the commissioner there. As a
follow-up, we developed part of their FEMA grant to have peer support be
part of the grant.

I just wanted to say sort of for the council and maybe for SAMHSA in the
future that the emergency response and recovery center was helpful, but
it\'s hard sometimes for them to recognize the importance of peers and
peer support and peer counseling, although it\'s very highly developed
in many areas of the country.

Sometimes, professionals are called on before peers are thought about,
but in order to really reach out to many people in different parts of
the country and develop a crisis plan, such as happened after 9/11 ‑‑
Project Liberty used peers a lot in New York City, and after the
tornadoes and after the bombing in Oklahoma, peer counselors were used.

We see this as the way to develop more in the way of consumer-run
organizations and peer support in affected areas, and also proactively
now other states are using this information to set up the crisis
planning that engages and involves consumers as peer counselors in the
future. So you don\'t have to go down, rush down and provide the
training at the time, but really do it ahead of time and have crisis
services and crisis planning be part of that, because there are parts of
the country where consumers are providing trauma-informed peer support
on the theme that was done here with children. That\'s being done with
adults now also by peers.

There is a write-up of this that people can pick up in the back. It is
on our website, howardu.org, if you want to see more information about
resources about Katrina.

Lastly, there is a webcast that\'s being done using some of the people
from Louisiana who have have done the training, and myself. It\'s
December 15th and is sponsored by SAMHSA.

MS. KADE: Thank you very much.

Any other public comments?

MS. ROGERS: Hi. I\'m Susan Rogers from the Mental Health Association of
Southeastern Pennsylvania. I spoke a little about this yesterday.

I wanted to thank Barbara for her question about seclusion and restraint
and what people are doing to get toward a zero policy. I wanted to again
mention the special section in Psychiatric Services, September of \'05.
There was an article about Pennsylvania\'s initiative.

Pennsylvania is working toward moving to a zero seclusion and restraint
policy. I would really like to respectfully just add that in
Pennsylvania, we are trying to get to zero with that.

This initiative began after Mr. Curie was our head of our mental health
system there. He was the one who initiated it. If anybody wants more
information about how we are doing it in Pennsylvania, please get in
touch with me at the Mental Health Association of Southeastern
Pennsylvania, srogers@mhasp.org. I\'d be glad to email you information,
or you can contact the state mental health authority. I\'m sure they can
provide that, too. Thank you.

MS. KADE: Thank you very much.

MS. THIEL: I\'m Thelma King Thiel with the Hepatitis Foundation
International.

I wanted to thank Dr. Clark and Beverly Watts Davis especially for
inviting us to train a lot of their grantees. We are scheduled to train
250 more in January and we\'ve already trained hundreds of them.

I also wanted to thank Ms. Jeb Bush for inviting me down to Florida to
meet with the Drug Policy Advisory Council a few months ago. As a result
of that, we have trained some of the folks, the counselors at the
Juvenile Justice Department. We have done training programs along with a
couple of the health departments, the Collard County Health Department,
and I just was down there recently to the Hillsboro County Health
Department, and they are going to invite us down again.

The response that we\'re getting on some of the evaluations that we had,
we are promoting liver wellness as an effective approach to get people
to change behaviors. We have done extensive evaluations. We\'re just
delighted at the response that we\'re getting.

I do want to thank everybody for collaborating with us. As a matter of
fact, SAMHSA just gave a grant to the Latin American Youth Center in
Washington, D.C. They had included us in their proposal and we\'re going
to be training their staff.

Again, the bottom line on all of our drug use problems is changing
people\'s behaviors. We\'ve got a real good start on that. Thank you so
much.

MS. KADE: Thank you very much.

If there isn\'t anymore public comment, I\'d like to ‑‑ yes?

MS. STUART: Carolyn Stuart with CONTAC out of West Virginia at the
National Technical Assistance Center.

I\'d just like to say thank you for letting us be a part of this
meeting, and just to comment in regard to the man with the Race Against
Drugs. One of the things that (inaudible) because as I listened to his
presentation, I realized that a large segment of the population will be
left out, because African Americans generally don\'t pay attention to
NASCAR.

MS. SULLIVAN: Not true. No, that\'s not according to the demographics
now.

MS. STUART: Just keep it inclusive and ensure that it reaches a large
segment.

MS. KADE: Thank you very much.

In closing, I want to summarize some of the highlights of some of the
follow-ups that we promised you.

In response to the request, Mr. Curie agreed to provide printed copies
of his remarks to the council members and that was done.

In request to a response from Mr. Stark, Ms. Power promised to provide
copies of \"Transforming Mental Health Care in America: The Federal
Action Plan Agenda: First Steps,\" and also the IOM report to the
council members. I believe that was done.

Mr. Curie asked for information on Medicaid Part D. We provided the
presentation today. I am going to be following up. I\'ll try to set up a
conference call with CMS before our June meeting, and we\'ll summarize
the highlights and the issues from the discussion this morning.

In response to Ms. Sullivan\'s request, I offered to provide the SAMHSA
scores on the OMB-mandated green standards for success. So what you have
is an explanation of those standards and the overall scoring. That\'s
publicly available information.

I think that\'s about it. There were other issues that you\'ll see in
the minutes, but those were the immediate follow-ups.

Any others? Toian, do you want to add anything else?

MS. VAUGHN: I want to thank everyone for coordination and the effort
that they made. This is a full agenda with everything that took place.

We will be leaving here shortly. I hope that you\'ll have an opportunity
to look at the Motorcraft as you exit the build and as you get on the
van to go downtown, because I think this afternoon we are going to be
visiting with the Secretary as he does his PSA announcement regarding
the Katrina campaign.

I also have been informed that you wanted to visit the Secretary\'s
command center, and we\'ve made arrangements for those who are not
leaving to do that as well.

MS. KADE: Then I call for an adjournment.

MS. SULLIVAN: Second.

MS. KADE: Thank you. See you in June, and talk to you earlier.

(Whereupon, at 12:06 p.m., the meeting was adjourned.)